Risk Management

Referral Form for Managed Care Patients

REFERRAL FORM FOR MANAGED CARE PATIENTS

Date:                                                  

Dr.                                                        has referred you to Dr.                                              

Phone:                                                

This referral is:

                                          Emergency

                                           Urgent (24-48 hours)

                                           Timely (1-2 weeks)

                                           When convenient

This appointment will have to be made for you by your primary care physician,

Dr.                                                       , who has been notified.  If there are any problems scheduling this appointment, please contact this office.

For office use only:

Outcome:                                                                                                                                           

(Original to patient. Copy to chart.)