Referrals

As Family Physicians, most often we take care of your health care needs right in our own office.

However, when further services are required, we can guide you to excellent subspecialty physicians and help coordinate the process. If you feel the need to see a consultant or receive a specialized service, please discuss this with us. Many health insurance plans require that we, as your primary care physicians, approve all referrals in advance before the insurer will pay for them. After you have made an appointment with a sub-specialist, please notify us at least 24 hours in advance so that we can take the necessary steps to properly authorize the referral. If we are not certain that a referral is appropriate, we may ask you to schedule a visit with us to review your condition before authorizing the referral.

Date (MM-DD-YYYY):
Patient eMail:
Physician:
	First:   Last:
Patient Name:
Patient Date of Birth:	Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908
Patient Phone #:
Insurance:
Policy # / ID #:
Reason for referral:
Has patient been seen for this condition by a provider in our practice?	Yes No
	Specialist Information
First Name:
Last Name:
Address:
Phone #:
Appointment Date:	Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2009 2008
# of visits requested: