I Am a Patient and Need a Referral

VERY IMPORTANT: Referrals are only valid for 6 months from the date they are issued. If you have not been seen by our office within the last 6 months for the referral you are requesting, you must schedule an appointment before referral processing can begin.

PROCESSING TIME: Valid referral requests may take up to 7 business days to process. Insurance companies may require additional documentation, prior authorization, medical records, or administrative review before a referral can be approved.

Referral Disclaimer / Patient Responsibility Notice: If you do not know which specialist you would like to see, please contact your insurance provider directly to obtain a list of specialists that you can choose from who are in-network with your insurance plan, once you find a physician you would like to see, please come back and fill out this form.

It is the patient’s responsibility to verify specialist participation and network status with their insurance carrier.
The PCP office is not responsible for locating a specialist that accepts your insurance plan.
The PCP office is not responsible for scheduling appointments with the specialist chosen by the patient.

First Name of Patient

Last Name of Patient

Phone Number

Preferred Contact Method

Checkbox Description

Phone
Email

Patient Date of Birth

Patient Social Security Number

REFERRAL / SPECIALIST INFORMATION

If other, please describe:

Physician Name Patient Wishes to See

REFERRAL DISCLAIMER / PATIENT RESPONSIBILITY

If you do not know which specialist you would like to see, please contact your insurance provider directly to obtain a list of specialists that are in-network with your insurance plan.

APPOINTMENT STATUS

Do you already have an appointment scheduled?

Appointment Date

Appointment Time

HOUR

MINUTE

AM/PM

INSURANCE INFORMATION

Insurance Carrier / Plan Name

Insurance Type (PPO/HMO)

Member ID

Group Number

Upload Front of Insurance Card

Browse (no files uploaded)

Upload Back of Insurance Card

Browse (no files uploaded)

PROCESSING TIME DISCLAIMER

Please Note:

Valid referrals for patients who have been seen within the last 6 months may take up to 7 business days to process.

Insurance companies are increasingly requiring additional documentation, prior authorizations, medical records, and administrative review before approving referrals. Due to the current strain on the healthcare system and the increased administrative burden being placed on primary care offices by insurance providers and payers, referral processing times have increased.

We kindly ask for your patience and understanding as our staff works diligently to process all patient referrals as quickly and accurately as possible.

Thank you for your patience while we care for all of our patients in as timely a manner as possible.

I understand that referral processing may take up to 7 business days.

*
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Patient Referral Inquiry Form

Thank you for submitting your Patient Referral Inquiry Form. We have received your form and are currently processing your request.

If you have any questions or need further assistance, feel free to contact us at 972-726-6464.

Best regards,
Neighborhood Medical Center

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