externalprovider.brightside.com
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34.149.30.234
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URL:
https://externalprovider.brightside.com/
Submission: On April 07 via api from US — Scanned from US
Submission: On April 07 via api from US — Scanned from US
Form analysis 1 forms found in the DOM
<form class="fs-mask" style="display: flex; flex-direction: column;">
<div style="display: flex; flex-wrap: wrap; margin-top: 2rem;">
<h3 style="margin-bottom: 18px; width: 100%;">Patient information</h3>
<div class="form-group"><label style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">First Name</label><input
data-testid="patientFirstName" id="patientFirstName" name="patientFirstName" required="" type="text" class="form-control" value=""></div>
<div class="form-group"><label style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Last Name</label><input
data-testid="patientLastName" id="patientLastName" name="patientLastName" required="" type="text" class="form-control" value=""></div>
<div class="form-group"><label style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Date of Birth</label><input
data-testid="patientBirthDate" id="patientBirthDate" name="patientBirthDate" placeholder="MM/DD/YYYY" required="" type="date" class="form-control" value=""></div>
<fieldset style="display: flex; flex-grow: 1; margin-bottom: 0px;">
<div class="form-group"><label for="Mobile Phone Number"
style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Mobile Phone Number</label><input
class="form-control fs-hide" name="Mobile Phone Number" placeholder="(555) 123-1234" required="" type="tel" value="" style="border: 1.5px solid rgb(204, 209, 219); color: rgb(13, 27, 64);"></div>
</fieldset>
<div class="form-group" style="max-width: 100%; width: 562px;"><label
style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Email</label><input data-testid="patientEmail"
id="patientEmail" name="patientEmail" required="" type="email" class="form-control" value=""></div>
<div class="form-group" style="margin-bottom: 0.5rem; width: 100%;"><label
style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Reason for referral (Optional)</label><textarea
data-testid="patientNotes" id="patientNotes" name="patientNotes" required="" rows="4" class="form-control"></textarea></div><span style="font-size: 0.875rem;">Brightside is available to people 18 and older. For a full list of the mental
health conditions we treat, <button type="button" style="color: rgb(77, 152, 219); display: inline-block; margin: 0px; text-align: center; text-decoration: underline; background: inherit; border: none; outline: none; padding: 0px;">click
here</button>.</span>
</div>
<div style="display: flex; flex-wrap: wrap; margin-top: 2rem;">
<h3 style="margin-bottom: 18px; width: 100%;">Provider information</h3>
<div class="form-group"><label style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">First Name</label><input
data-testid="firstName" id="firstName" name="firstName" required="" type="text" class="form-control" value=""></div>
<div class="form-group"><label style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Last Name</label><input
data-testid="lastName" id="lastName" name="lastName" required="" type="text" class="form-control" value=""></div>
<div class="form-group"><label style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Organization
<span>(Optional)</span></label><input data-testid="organization" id="organization" name="organization" required="" type="text" class="fs-unmask form-control" value=""></div>
<fieldset style="display: flex; flex-grow: 1; margin-bottom: 0px;">
<div class="form-group"><label for="Fax" style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Fax
(Optional)</label><input class="form-control fs-hide" name="Fax" placeholder="(555) 123-1234" required="" type="tel" value="" style="border: 1.5px solid rgb(204, 209, 219); color: rgb(13, 27, 64);"></div>
</fieldset>
<fieldset style="display: flex; flex-grow: 1; margin-bottom: 0px;">
<div class="form-group"><label for="Phone Number" style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Phone
Number</label><input class="form-control fs-hide" name="Phone Number" placeholder="(555) 123-1234" required="" type="tel" value="" style="border: 1.5px solid rgb(204, 209, 219); color: rgb(13, 27, 64);"></div>
</fieldset>
<fieldset style="display: flex; flex-grow: 1; margin-bottom: 0px;">
<div class="form-group"><label for="Phone Number"
style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Extension (Optional)</label><input
class="form-control fs-hide" type="tel" value="" style="border: 1.5px solid rgb(204, 209, 219); color: rgb(13, 27, 64);"></div>
</fieldset>
<div class="form-group"><label style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Npi Number</label><input
data-testid="npi" id="npi" maxlength="10" name="npi" required="" type="tel" class="form-control" value=""></div>
<div class="form-group"><label style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Email
(Optional)</label><input data-testid="email" id="email" name="email" required="" type="email" class="form-control" value=""></div>
<div class="form-group"><label style="color: rgb(46, 73, 133); font-family: Outfit; font-size: 0.75rem; font-weight: 700; letter-spacing: 2.4px; margin-bottom: 0px; padding-bottom: 0.5rem; text-transform: uppercase;">Tax ID</label><input
data-testid="tin" id="tin" maxlength="9" name="tin" required="" type="tel" class="fs-unmask form-control" value=""></div>
</div><button disabled="" type="button"
style="appearance: none; align-items: center; background-color: rgb(204, 209, 219); border-color: rgb(46, 73, 133); border-radius: 30px; border-width: 1px; color: rgb(94, 104, 131); font-family: "DM Sans"; font-size: 0.875rem; font-weight: 700; justify-content: center; letter-spacing: 2.4px; line-height: 1.2; margin-top: 1.5rem; padding: 1rem 120px; text-decoration: none; text-transform: uppercase; align-self: center; max-width: 562px; width: 100%; border-style: none;">Submit</button>
</form>Text Content
* Our Treatments * Psychiatry * Therapy * Psychiatry + Therapy * Reviews * FAQ * Business * Payer * Employer * Provider * Resource Center * Patient Referral * Login * Search * Get in Touch PATIENT REFERRAL PORTAL Complete the form below to submit your referral. PATIENT'S STATE Select the patient's state PATIENT INFORMATION First Name Last Name Date of Birth Mobile Phone Number Email Reason for referral (Optional) Brightside is available to people 18 and older. For a full list of the mental health conditions we treat, click here. PROVIDER INFORMATION First Name Last Name Organization (Optional) Fax (Optional) Phone Number Extension (Optional) Npi Number Email (Optional) Tax ID Submit By submitting this referral, you are formally acknowledging that the information provided herein is, to the best of your knowledge, entirely accurate. Furthermore, you are representing yourself as a healthcare provider or representative of a healthcare entity legally authorized to treat the aforementioned patient, and that dissemination of any patient health information from Brightside Health, Inc. to you or the entity you represent is being requested for the sole purpose of rendering future care to the referred patient. Brightside Health strictly adheres to all applicable rules and regulations governing every patient's protected health information (“PHI”). Should you wish to know more about the ways in which Brightside Health may use or disclose PHI, we encourage you to view our Notice of Privacy Practices. We're committed to delivering life-changing anxiety and depression care to everyone who needs it. SERVICES * Medication * Therapy * Self-care * Reviews * Student Discount * FAQ COMPANY * About Us * Careers * Patient Referral * Contact Us * Sitemap LEGAL * Terms of Use * Privacy * Telehealth Consent * Notice of Privacy Practices * Transparency in Coverage * Member Rights and Responsibilities PARTNER WITH US * Payer * Employer * Provider * Become an Affiliate -------------------------------------------------------------------------------- LET'S STAY IN TOUCH. * * * * Copyright Brightside Health Inc. 2023 * Treatment * Medication * Therapy * Psychiatry & Therapy * Learn * Anxiety * Depression * Our Providers * Our Therapists * Our Medications * Our Results * Blog * About * Reviews * About us * Refer a Friend * Contact * Careers * Business * Payer * Employer * Provider