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Referring a Patient Just Became Easier!
Please select one of the following options
For each option you will need:
Patient's Demographic Information: Name, Date of Birth, Sex, Best Call Back Number, Mailing Address
Patient's Insurance Information: (Primary & Secondary if applicable) Insurance Name, Member ID. Group Number, Insurance Phone Number for Verification
Services: What Services are You Referring For
Release of Information* Not required but recommended
Need a release of information?
We now have an online form as well!
All medical records can be emailed to firstname.lastname@example.org or can be faxed to (949) 579 -9102
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