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Referral Request

If your situation requires immediate attention please call our office (at 789-9600); or if this is Medical Emergency, dial 911.

Note: We can only reply to 1) the patient, 2) the minor patient's parent or legal guardian, or 3) someone an adult patient has authorized us to talk with by placing their name on the HIPAA Release form obtained from our office. Forms are also available from our website: www.pfmindy.com.

 

Patient Demographic Information

Please provide First and Last name. Also, include Middle Initial please.
Provide Primary Insurance if not listed above.
 
 

The following questions pertain to you.

If you are requesting a referral for someone else, please provide your full name and your relationship to the patient.
 

Referral Information

You may need to contact you Specialty Provider for the following information.

Referrals may take up to 2 weeks to complete, depending on your insurance. Please call the office if this is an urgent medical need.
If you are from a Specialty Provider's Office, please supply the requested CPT Code.
If you are from a Specialty Provider's Office, please supply the requested ICD Code
Please list the name of the Specialty Provider/Company to whom you want referred.
 
 
 

To receive an email response, you must have an active Portal Account

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