MEDICAL REFERRAL FORM

RETURN COMPLETED REFERRAL REQUEST FORM TO
ATTENTION	FAX
PHONE	EMAIL
FORM COMPLETED BY	PHONE	DATE

REFERRED BY
REFERRING MD	PHONE
SPECIALTY	FAX
MD SIGNATURE	EMAIL
PCP if different	PCP PHONE

PATIENT INFORMATION
LAST NAME	FIRST NAME AND MI
DATE OF BIRTH	FEMALE / MALE
INTERPRETER REQUIRED?	LANGUAGE REQUIRED
GUARDIAN NAME	GUARDIAN RELATIONSHIP
PATIENT’S ADDRESS	CELL PHONE
HOME PHONE
WORK PHONE
EMAIL
REFERRAL DIAGNOSIS	ICD-9

SERVICE REQUESTED
REASON FOR REFERRAL
PATIENT AWARE OF REASON FOR REFERRAL? IF NOT, PLEASE EXPLAIN.
SERVICE / SPECIALTY REQUESTED	PHYSICIAN REQUESTED
TYPE OF SERVICE REQUESTED	CONSULTATION	TRANSFER OF CARE new patient evaluation / management
ADDITIONAL COMMENTS

INSURANCE INFORMATION
AUTHORIZATION REQUIRED?	YES	NO	AUTH #	# OF VISITS	AUTH EXP. DATE
PPO	HMO	OTHER	INSURANCE PLAN
INSURANCE ID	MEDICAL GROUP	PHONE #
INSURANCE HOLDER’S NAME	RELATIONSHIP TO PATIENT	DOB

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