I Am a Specialist Office Requesting Referral Information

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.

SPECIALIST INFORMATION

Person Submitting Request

Specialist Physician Name

Specialist NPI Number

Office Address Where Patient Will Be Seen

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Phone Number for That Location

Fax Number for That Location

Email Address for Specialist Office

PATIENT INFORMATION

First Name of Patient

Last Name of Patient

Phone

Patient Date of Birth

Insurance on File for Patient

Browse (no files uploaded)

Preferred Contact Method

Checkbox Description

Phone
Email

APPOINTMENT STATUS

Has the patient already been scheduled?

Appointment Time

HOUR

MINUTE

AM/PM

Appointment Date

REQUEST DETAILS

What is being requested?

Referral Authorization
Medical Records
Office Notes
Labs
Imaging
Demographics
Insurance Information
Prior Authorization
Other

IF OTHER PLEASE DESCRIBE

*
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I Am a Specialist Office Requesting Referral Information

Thank you for submitting your Specialist Office Request 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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