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Request Referrals Online!

  • No referral will be faxed to anyone.
  • All referrals must be mailed or picked up.
  • It is a patients responsibility to take a referral with them to the specialist appointment.
  • Referrals take 3-4 days to complete.
  • Aetna Patients must use referral within first 90 days.

Many of our patients belong to an HMO or PPO ("managed care plan"). It is your responsibility to be familiar with the insurance plans requirements regarding referrals, emergency room visits and covered benefits. Most managed care plans require a patient be seen by their doctor prior to seeing a specialist. Contact your insurance representative or employee benefits office if you are unsure about these details.

When a referral is needed, please let us know in advance. If you see a specialist without first requesting a referral, you assume financial responsibility for the service. We do not issue referrals after the fact. Please fill out this form and someone will call or email you when your referral is ready. The average time for completion is 5 days.

 

Fields marked with the red asterisk (*) are required fields and must be filled out.
  Patient Last Name:
* 		Patient First Name:
* 		 
  Date of Birth:
* ex. mm/dd/yyyy		    
  Home Phone:
* --		 Work Phone:
--ex 		 
  Email:
* 		Primary Physician:
  
  Insurance:
  
  Request Referral to: Date of Appointment:
mm/dd/yyyy		  
  Type of Specialist:      
  Reason for Referral:
    
       
     
Click here if you are a new patient or need to update your demographic information.
Click to request an appointment online! Click here for any billing questions. Click for prescription refills. Click here for referral requests.
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