Provider Referral Request Formsiteadmin2019-05-02T21:02:22-06:00 Please complete the form or download and print the referral form.Download Referral Form Provider Referral Form If you are human, leave this field blank. Referring To: Location * Select Location 6115 New Copeland Rd, Ste: 430, Tyler, Texas 75703 3201 US Highway 380, Suite 101, Crossroads, Texas 76227 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: 121234567891011 : 0030 AMPM 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) Referral Accepted? Yes NoNo (If no please explain) Appointment Scheduled with: Date & Time: Patient refused scheduling Patient prefers to contact specialist to schedule at a later date Request for additional supporting clinical information (please detail): Person completing confirmation: Date of Confirmation: Submit
