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Access Portal Account Instructions Appointment Request -NEW PATIENT Appointment Reschedule / Cancellation Request Prescription Refill Request Question for Doctor or Nurse Referral Request Request New Portal Account

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

Patient's Full Name *

Please provide First and Last name. Also, include Middle Initial please.

Date of Birth *

Select the Patient's Primary Insurance *

Other Primary Insurance

Provide Primary Insurance if not listed above.

The following questions pertain to you.

Your Full Name if other than the patient

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

How do you prefer to contacted? *

Phone

Phone Number Email Address *

This phone number is my:

Cell phone

Home phone

Work phone

Other

Referral Information

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

Reason for Referral *

Referrals may take up to 2 weeks to complete, depending on your insurance. Please call the office if this is an urgent medical need.

Have you requested a referral for this in the last month? *

Yes

CPT Code

If you are from a Specialty Provider's Office, please supply the requested CPT Code.

ICD Code

If you are from a Specialty Provider's Office, please supply the requested ICD Code

Name of Specialty Provider *

Please list the name of the Specialty Provider/Company to whom you want referred.

Specialty Provider's Phone Number *

Specialty Provider's Fax Number *

Specialty Provider's Address *

Specialty Provider's NPI

Specialty Provider's Tax ID

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

* Required field