Patient Referral Form
Be sure to attach photos of both the front and back of the patient’s
insurance card. We do not accept Medicaid at this time.
Group NPI: 1982209680
Instructions: Please complete this form and send it to us via email or fax using the contact information above. Be sure to attach photos of both the front and back of the patient’s insurance card. We do not accept Medicaid at this time.
The confidentiality of email and fax transmissions cannot be guaranteed as the internet is not a secure medium. Please use at your discretion. This transmission, including any accompanying records, may contain Protected Healthcare Information (PHI) and is intended only for the individual or entity addressed, subject to HIPAA privacy and security provisions. If you are not the intended recipient, any unauthorized use, disclosure, copying, or distribution is strictly prohibited. If you received this in error, please delete it and contact the sender.