Referrals

It is the goal of our clinicians to provide our patients the best health care possible. In keeping with that goal there will be times when further services are required. Your PCP (Primary Care Physician) will direct you to a qualified specialist affiliated with a local practice within our referring service network. This is done to coordinate your care with specialists with whom we most closely communicate, resulting in better quality assurance and efficiency.

Infrequently your PCP will refer you to a physician outside of our usual network of specialists. This is generally only if the expertise needed to handle a particular issue is not available from a specialist affiliated with our practice.

When you make your appointment with the recommended specialists it is then your responsibility to contact our office to request your insurance referral.

The following are guidelines to help in the processing of the referrals:

1.     Please do not self refer to other specialists. Your care is coordinated by your PCP.

2.     You must contact our office at least 5 business days prior to the specialist appointment to allow sufficient time for reviewing and processing.

3.     If you are unable to get an appointment within a reasonable period of time please contact our office and we will assist you in getting a timely appointment.

4.     If you feel there is a reason to be seen outside of our local network please contact our office for appointment with one of our providers to discuss your concerns.

5.     If your PCP does not agree with the necessity of a self referred specialist appointment and does not approve the referral you will be responsible for payment to the specialist.

If you have any questions or concerns regarding our referral policy please call our Referral Coordinator @ 978-526-4311 ext 6608.

Thank you

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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 2010 2009 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
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 2011 2010
# of visits requested:

 

 

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