Provider Web Referral

Patient Information

Patient’s first name

Patient’s last name

Patient’s DOB

Primary phone type Select Home Cell Work

Patient’s primary phone

Secondary phone type Select Home Cell Work

Patient's secondary phone

Best contact days

Best contact times

Patient's address

Patient's address 2

Patient's city

Patient's state Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Patient's zip

Patient's preferred language

Is it ok to leave a voicemail?

• Yes
• No

Is patient hearing impaired?

• Yes
• No

Patient's insurance provider Aetna Better Health of Michigan BCBS of MI/Blue Care BCBS Other Berrien (ABW) Blue Cross Complete BlueCaid (BCBS Medicaid) Doesn’t Know Genesee Health Plan (ABW) HAP Midwest Health Plan Harbor Health Plan Indian Health Service Ingham (ABW) McLaren Health Plan Medicaid Medicaid/MI Health Medicare Medicare and Medicaid (dual-eligible) Meridian Health Plan Molina Healthcare of Michigan Other Physicians HP of Mid-MI Priority Health Refused Total Health Plan UnitedHealthcare Community Plan (formerly Great Lakes Health Plan) Upper Peninsula HP Veterans Administration

Insurance Member ID

Clinic Information

Type of HIPAA covered Entity:

Provider First Name

Provider Last Name

Contact First Name

Contact Last Name

Clinic/organization name

Clinic address

Clinic address 2

Clinic city

Clinic state Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Clinic zip code

Clinic fax number

Authorization