Referral Requests


Reminder - While most referrals are processed electronically, please keep in mind that our office still requires a one week notification for ALL referral requests to allow for appropriate processing with your insurance carrier. It is your responsibility to determine whether or not your insurance plan requires a referral and to determine whether or not your plan will cover the specialist of your choice. 

As in the past and as per insurance policy, there will be NO BACKDATING of any referral. If such a request is made, it will be DENIED.

If our office is not given the one week notification period for your referral, you may be subject to an additional processing fee in order to complete your request.


Your name / person completing this form -

Child's Name -

Date of Birth - (please enter as Month-Day-Year, for example - 01-01-06)

Parent's Name -

Contact Phone Number - (please include area code)

Your child's regular doctor is

The specialist your child will be seeing -

The specialist's NPI number - (you can obtain this from the specialist's office when you call them for an appointment)

The specialist's field -

Date of your appointment - (please enter as Month-Day-Year, for example - 01-01-06)

Time of your appointment - (if available / known)

Reason for your appointment -

Your Insurance Carrier - (i.e. - Aetna, Horizon BC/BS, Cigna, etc.)

Your insurance ID number -

Your insurance group number -




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