Referring Provider

Referring Provider Information

We must receive this form, demographic information, insurance information (PRIMARY AND SECONDARY), office notes, labs and scans to schedule an appointment. Please let us know if your patient does not want to use the website or does not have internet access and we will mail them a New Patient Packet to be completed and brought with them to their appointment.

To use our electronic new patient consultation submission process, please choose this option:

Medicaid Information For Referring Providers

When you provide your patient with the date and time of their appointment, PLEASE notify them that if they have ANY change in insurance, primary OR secondary, to call our office prior to the appointment date. We have confirmed that we participate only with the insurance information you provided at the time you requested the appointment.


We DO NOT accept new Medicaid patients, nor do we participate with the Medicaid MCO’s. There are other insurances we do not participate with as well. Please advise the patient that if they arrive with an insurance we do not participate with, they will not be seen.


We sincerely appreciate your referral and appreciate the opportunity to be a part of your healthcare team.