Mindera Corp

Please complete and submit the following information to Mindera Health to arrange Mind.Px testing for your State of Connecticut Care Compass Member. 

 

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  • State of Connecticut Care Compass Mind.Px Request Form
Practice and Provider Information
Practice Name *
Practice Address *

Street, Suite, City, State, and Zip

Practice Phone Number *

Phone

How would you like the Mind.Px report to be delivered? *
Provider Name *

The name of the licensed healthcare professional, authorized to order this test, who will sign the test requisition and attest that the test is medically necessary.

Provider's Personal Email *

This will be the email address where the Test Requisition Form will be delivered for DocuSign.

Provider NPI Number *
Patient Information
Patient First Name *
Patient Middle Name

This field may be left blank if the patient has no middle name. 

Patient Last Name *
ICD-10 Code *

Select all that apply. If other, please specify in the field beneath the "other" checkbox.

Patient Date of Birth *
Set to now
Patient Sex *
Patient Address, Street *
Patient Address, Apartment/Unit Number
Patient Address, City *
Patient Address, State *
Patient Address, Zip *
Patient Phone Number *
Patient Email

Optional 

Insurance Information
Insurance Name *
Patient Relationship to Subscriber *
Subscriber ID Number *
Group Number
Rx Group Number *

In order to be eligible for this program, the patient's Rx group number must match one of the numbers included in this dropdown list. Please contact the state of Connecticut Care Compass client services at 858 258-6493 with any questions.