Franklin M. Rivers Jr., MD PA
Private, self-pay telemedicine practice providing evaluation and continuing care under the Texas Compassionate Use Program
Instructions to the Referring Physician
A formal physician referral is not essential, but would be appreciated
Please complete this form or provide a referral letter containing the requested information. The referral should identify the medical condition believed to qualify the patient for consideration under the Texas Compassionate Use Program and provide sufficient clinical information for an independent medical evaluation.
1. Patient Information
Patient’s full legal name:
Date of birth:
Telephone number:
Email address:
Home address:
Is the patient a permanent Texas resident?
☐ Yes
☐ No
☐ Unknown
2. Referring Physician Information
Physician’s name:
Medical specialty:
Practice or organization:
Texas medical license number:
Practice address:
Telephone number:
Direct telephone number, if different:
Secure fax number:
Email address:
Preferred method of communication:
☐ Secure website communication
☐ Secure fax
☐ Telephone
☐ Other: ___________________________________________
3. Condition for Which Referral Is Made
Primary medical or psychiatric condition for which evaluation is requested:
Date or approximate date of diagnosis:
Please explain why you believe this condition may qualify the patient for evaluation under the Texas Compassionate Use Program:
Please describe the severity, duration, and present status of the condition:
Relevant symptoms and effect on the patient’s daily functioning or quality of life:
Is the diagnosis confirmed by appropriate clinical evaluation, testing, or specialist assessment?
☐ Yes
☐ No
☐ Partially
☐ Unknown
Please identify relevant diagnostic studies, consultations, or supporting records:
4. Previous and Current Treatment
Please identify the treatments previously attempted for the condition, including medications, therapy, procedures, rehabilitation, counseling, or other interventions.
5. Current Prescription Medications
Please list all current prescribed medications, not only medications used for the qualifying condition.
| Medication | Strength | Dose and frequency | Prescribing clinician | Purpose |
|---|---|---|---|---|
| __________ | __________ | __________ | __________ | __________ |
| __________ | __________ | __________ | __________ | __________ |
| __________ | __________ | __________ | __________ | __________ |
| __________ | __________ | __________ | __________ | __________ |
| __________ | __________ | __________ | __________ | __________ |
Attach an additional medication list if necessary.
6. Additional Medical and Psychiatric Conditions
Please list any other significant medical or psychiatric conditions currently affecting the patient:
Relevant surgical history:
Known allergies or adverse medication reactions:
7. Substance-Use History
To the best of your knowledge, does the patient have a current or previous history of:
| History | Yes | No | Unknown | Explanation |
|---|---|---|---|---|
| Alcohol misuse | ☐ | ☐ | ☐ | __________________ |
| Cannabis misuse | ☐ | ☐ | ☐ | __________________ |
| Opioid misuse | ☐ | ☐ | ☐ | __________________ |
| Other substance-use disorder | ☐ | ☐ | ☐ | __________________ |
Additional information:
8. Clinical and Safety Considerations
To the best of your knowledge, does the patient have any of the following?
| Condition or concern | Yes | No | Unknown |
|---|---|---|---|
| Pregnancy or breastfeeding | ☐ | ☐ | ☐ |
| History of psychosis | ☐ | ☐ | ☐ |
| Active suicidal thinking or recent suicide attempt | ☐ | ☐ | ☐ |
| Significant cognitive impairment | ☐ | ☐ | ☐ |
| History of medication misuse or diversion | ☐ | ☐ | ☐ |
| Recurrent falls or serious balance impairment | ☐ | ☐ | ☐ |
| Serious cardiovascular disease | ☐ | ☐ | ☐ |
| Significant hepatic or renal impairment | ☐ | ☐ | ☐ |
| Other condition affecting treatment safety | ☐ | ☐ | ☐ |
Please explain every “Yes” response:
Are you aware of any reason that cannabinoid treatment may present an unusual or unacceptable risk for this patient?
☐ No
☐ Yes—please explain:
9. Records Included with This Referral
Please indicate the records being submitted:
☐ Recent office notes
☐ Relevant specialist consultations
☐ Current medication list
☐ Problem list
☐ Relevant laboratory results
☐ Imaging or diagnostic reports
☐ Hospital or emergency department records
☐ Psychiatric or psychological records
☐ Prior treatment records
☐ Other: ___________________________________________
10. Continuing Care and Communication
Will you continue to provide the patient’s general or specialty medical care?
☐ Yes
☐ No
☐ To be determined
May Dr. Rivers contact you to discuss the patient’s condition, treatment history, or safety considerations?
☐ Yes
☐ No
Best telephone number and times for physician-to-physician communication:
Additional information or recommendations for Dr. Rivers:
11. Referring Physician Attestation
I certify that the information supplied in this referral is accurate to the best of my knowledge. I am referring this patient for an independent medical evaluation by Franklin M. Rivers Jr., MD.
I understand that this referral does not direct or require Dr. Rivers to accept the patient, determine that the patient qualifies under the Texas Compassionate Use Program, or prescribe low-THC cannabis. Any such decision will be based upon Dr. Rivers’ independent medical evaluation, professional judgment, and applicable Texas law.
Referring physician’s printed name:
NPI:
Signature:
Date:
Secure Submission Instructions
Please submit this form and supporting records through the secure physician-document upload function on the practice website.
Do not send protected medical information through ordinary, unsecured email.
If the referring physician prefers to communicate personally with Dr. Rivers, physician-to-physician telephone communication may be arranged through the practice’s designated professional telephone number.
Submit via fax to fax number 833-303-1572