Refer a Patient ✆214-613-2019

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Refer a Patient ✆214-613-2019

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Refer a Patient

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Refer a Patient

September 17, 2019 by webadmin

Patient Referral Request Form

Contact us @214-613-2019 or complete the form below to request management of a prior authorization/precertification request.

A Prime Care Health Solutions team member will contact you to complete your request.

Patient Referral Request Form

Step 1 of 5

20%

Select the program or service you’d like to refer your patient to at Prime Care Health Solutions*
- Comprehensive Pharmacy Concierge Service
  (medication management & adherence & lifestyle coaching)
- Nutritional Care Services
  (detoxification & whole body wellness)
- Medication Management
- Medication Adherence Program
- Medication Reconciliation & Reduction Service
- Smoking/Tobacco Cessation Program
- Opioid Addiction Prevention Program
- Tele-health Pharmacy Disease Management Program
- Hypertension Management Program
- Hypertension Prevention Program
- Diabetes Management Program
- Lifestyle Wellness Programs
  (events, workshops & classes)
- Workplace Wellness Program
- Weight Management Program
- Private 1-1 Health & Wellness Coaching Service
- Women’s Health Coaching Service
- Family Planning – Hormonal Care & Fertility Care service
- Men’s Health Coaching Service
- DPP

Save and Continue Later

Referring Physician Information
Provide information about the provider requesting the referral
Last Name*
First Name*
Middle Name
NPI Number
Specialty

Save and Continue Later

Practice Contact Information
Provide information about the contact person for referral
Last Name*
First Name*
Title
Clinic / Facility Name*
Clinic / Facility Address*
City*
State*
Phone number*
Fax
Email address

Save and Continue Later

Patient Information
Last Name*
First Name*
Middle Name
Date of Birth
Date Format: MM slash DD slash YYYY
Address
City
State
Preferred Phone number*
Alternate Phone number
Email address

Save and Continue Later

Appointment Information
Preferred Appointment Date*
Date Format: MM slash DD slash YYYY
Preferred Appointment Time
e.g. morning, afternoon, 2pm, etc
Additional comments about this patient referral
Email
This field is for validation purposes and should be left unchanged.

Save and Continue Later

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