Referral Request

Many insurance companies require that a referral be completed prior to having specialty care provided. If the referral is not obtained from the insurance company, the patient will be responsible for the full balance of all incurred charges.

It is the responsibility of the parent or guardian to submit a referral request at least five business days prior to the child's appointment with the specialist. Only under extreme emergency conditions will same day referrals be approved and completed. Referrals cannot be back-dated and in most cases, your insurance requires 24 to 48 hours notice to approve (giving us authorization).

Have you verified with your insurance company that you need a referral for the problem that your child has? If not, please stop here and call your insurance company. If yes, then proceed.

Have you made the appointment with the specialist? If not, stop here and call the specialist's office to make an appointment. If yes, then proceed.

Please fill out the request form making sure you include in the message all the items below or Click Here for a printable (PDF) copy of the Referral Request form that you will print, fill out, and mail or fax to us.

We require a minimum of 48 hrs to complete your referral. We will either email you or call you to confirm that the referral was done. Last minute requests will only be done in extenuating circumstances and will require you to wait in the specialist office a few hours until the referral can be processed by our staff.

Please make sure you include the all of the following information listed below, in the message section. Incomplete forms will not be processed:

-Your Child's Name
-Specialist Name
-Physician Specialty Needed
-Specialist Office Phone and Fax
-Specialist NPI Number
-Date of Appointment
-Reason for Referral