Insurance Referral Request

Date of request:

Please allow 5 business days to complete the referral

Patient Name:

Patients date of birth:

Name of current insurance:

Who referred the patient to the specialist/facility?

Who are we referring the patient to?

Last Name:

First Name:

Office address:

City:

State:

Zip:

Telephone number:

Fax number:

Specialist appointment date and time?

Reason for referral/diagnosis:

Telephone number parent/guardian can be reached:

Referrals are required by your insurance when seeing any other doctor/specialists other than Edgewood Center Pediatrics. Without a referral your insurance may not cover the cost of any medical treatment you or your child obtain. Please requests referrals at least 5 days prior to your appointment with the specialist/facility.

As part of our contract with your insurance company the following is required to complete any referral request:

The patient must be a current patient in our office and seen within the last year.
The patient must be referred to the specialist/facility by one of Edgewood Center Pediatrics providers or provide documentation that another medical provider (ER, other specialist) has referred you to the specialist/facility.
The patient must have a well exam in our office within the last year.

Unfortunately, without this information the requests cannot be processed. We appreciate your understanding and patience with this policy.

Name of person completing this form

Date