Fax form

Specialist referral request
For your convenience, use this form to fax your request for insurance referrals for specialist appointments that have already been made. Please do not use this form for first time referrals.

Of course, you may always call your primary office to request prescription refills.

Instructions
Print this form. Please be sure to fill out all the blanks to ensure proper processing of your request. Fax it to your primary office below.

• Download this pdf form and print it using Adobe Acrobat Reader.

Primary office fax numbers:

Camillus office FAX: (315) 487 - 3485

Liverpool office FAX: (315) 652 - 4679

Please fill out completely

Patient / parent information

Patient's name: _______________________________________________

Patient's birthday: ______________________________________

Patient's primary care physician: _________________________________

Parent's name: _________________________________________

Address: ____________________________________________________

Phone number: _________________________________________

Specialist and insurance information

Specialist: ___________________________________________________

Appointment date: _________________ Appointment time: _____________

Reason for referral: ____________________________________________

Insurance provider: ____________________________________________

Insurance policy number: ________________________________________