Provider Referral Request Form

Referring To:

Location *

Please Schedule: *

Urgent-- Referring physician called

Routine Appointment with Specific Physician listed

First Available with any Physician

*Select all that apply

Referring Provider’s

Referring Provider's Name *

Fax

Phone *

Type of Referral *

Evaluation consultation with treatment recommendations that primary care physician will continue to follow

Evaluation consultation with assumed care for this condition

Evaluation consultation with treatment recommendations and shared care

Specialist to Specialist*–Secondary Referral *Send copy of this referral to patient’s primary care physician.

Other (designate)Other (designate)

Patient Information

Patient Full Legal Name: *

DOB *

If patient is under 18 years old – Parent Contact Name:

Preferred Phone:

Best time to call:

:

Special Patient Considerations:

Patient Insurance Information:

Patient’s Primary Care Provider: *

Phone: *

Fax:

General Information

Reason for Referral (Clinical Question): *

Comments/Considerations Related to Clinical Question: **Please include recent labs, pertinent imaging reports, medication list, problem list, allergies, and relevant clinical notes.**

Patient aware of reason for referral? *

Yes

NoNo

If No, Please Explain

Referral Conformation

(Internal Use Only)