Faxing Referrals

Fax instructions for Specialty Care, Surgery or Procedures

• 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, including CPT and ICD-9 codes
• Provider’s contact information, including name of office contact