Referring Providers

To submit a referral, you can choose between the following options:

1) Download and complete the referral form PDF linked below and fax back to (623) 889-2452.

2) Use the form below, fill it out, and click “Submit”.

Submit Referral

PLEASE SEND MOST RECENT EXAM NOTE WITH REFERRAL

PROVIDER INFORMATION

Referring OD’s Name

Contact Name

Phone #

Fax #

PATIENT INFORMATION

Patient Full Name

Patient Date of Birth

Phone

Medical Insurance Plan: (We will be billing the patient’s medical insurance)

Primary Coverage

Secondary Coverage

Diagnoses

Notes

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