Town Center Family Medicine: Specialist Referral Request

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Specialist Referral Request

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 3-5 days.

Please fill in the following information. Fields marked with the red asterisk (*) are required fields and must be filled out.

Patient's Last Name*	Patient's First Name*
Street Address
City	State	Zip Code
Home Phone* --	Work Phone -- ext.
E-mail*	Date of Birth* (ex. mm/dd/yyyy)
Primary Provider *( Physician or Nurse Practitioner)

Insurance
Request Referral To	Date of Appointment (ex. mm/dd/yyyy)
Type of Specialist
Reason for Referral—Diagnosis

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