Request an appointment for a patient at an Alignment Care Center

For assistance contact the Referrals/Authorization Dept at 844-215-2442

Practice Location * Date *

Please choose primary care provider either MD or PAC/FNP

PCP MD FNP/PAC Type of Referral Health Plan Member ID * Last Name Patient First Name Patient Sex * Date of Birth * Address City State Zip Code Referred to Primary Diagnosis Secondary Diagnosis ICD-10 Codes

Reason for Referral (Send Progress Notes/diagnostic studies)

Person Completing Form Telephone Number

DO NOT COMPLETE SECTION BELOW

Tracking Number Appointment Date Status Other information Specific Instructions Alignment Healthcare Staff Date Time