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.)

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