Referrals

If you would like for us to E-mail a referral so that insurance will pay for treatment from your specialist, please complete the following information and we will respond to your request.

DISCLAIMER: SUBMITTING THIS INFORMATION WILL AUTHORIZE SOPHIA MEYER FAMILY MEDICINE TO RELEASE PRIVATE INFORMATION TO THE E-MAIL ADDRESS/FAX/ADDRESS/PHONE NUMBER THAT HAS BEEN PROVIDED IN THIS FORM, THEREFORE RELEASING SOPHIA MEYER OF ALL LIABILITY IN RELEASING THIS INFORMATION.

Note: We will not issue referrals on patients if we have not seen them in our office first.

* All Fields Are Required!

* Patient Name:  
* Patient DOB: i.e. mm/dd/year  
* Phone: i.e. 469-555-1212  
* Please List Any Allergies:
(If None, Type In None)
 
* Physician Requesting Referral:  
* Email To Send This Referral::  
* Insurance Carrier Needing Referral:  
* Comments:  
   

 

 

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