REFERRALS
The process of creating a referral for an HMO patient to go to
a specialist requires gathering a large amount of information and transmitting
it to the insurer.
Please note that it is the policy of most insurers that you must be seen by your
primary care doctor before they can refer you to a specialist.
Please fill in the requested information below. We may need to contact you for clarification.
| Your name | |
| Your doctor | |
| Reason for the referral | |
| Type of specialist | |
| Name of specialist | |
| Location of specialist (city) | |
| Is this a chronic problem? | Yes No |
| Has one of our doctors seen you for this problem? |
Yes No |
| How would you like to receive this referral? | Pick
up Mail
other: |
| Your work phone | |
| Your home phone | |
| Your email address | |
| Other comments |