Fax Instructions

Faxing Referrals

For referrals, please fax the following information:

• Patient contact information: name, address, phone number, date of birth

• Copy of insurance card (front and back)

• Insurance authorization, if required

• What service is requested (consultation, diagnostic testing, etc)

• Please give specific provider’s name if requested/known

• Diagnosis, reason for referral

• Copies of progress notes, diagnostic test results that pertain to this visit

• Provider’s contact information, including name of office contact

For more information, see Contact Info, Referrals, and Consultations