Referral Request Form
Health Associates of South Philadelphia

We need all this information to make up your referral. If you don't know the answers to some questions, leave the space blank, but we may have to call you to get more information.

Some of the information, like procedure codes, is in reference books in our office You only need to include it if the doctor you are seeing gave you the numbers to make sure the referral is accurate.

If your insurance company still uses your social security number as an ID, give only the last 4 digits of your social (for instance, xxx-xx-2023-00 instead of 232-41-2023-00)

Please allow plenty of time for your referral to be made up. We do hundreds of these every week, and they must be reviewed and signed by your doctor after office hours, so we can't give same day referrals.

Leave at least 2 business days. If your doctor has any questions and we must contact you for more information, it will take longer.

Faxing referrals can be done for your convenience if you have the fax number, but again, because we process hundreds of these things, your referral could wait longer for the fax machine to be free than it would take for you to drop by to pick it up.

Before you start, please check your coverage information about what things need referrals. You may save yourself a lot of time:

No referrals are needed for gynecologists in the state of Pennsylvania except for cancer, bladder problems, or infertility.
You don't need referrals for abortions,either, though government plans don't cover them at all.
You also don't need a referral for mental health care in Pennsylvania, and your plan should have provided a phone number for you to call to find one of their doctors.
Most insurers don't require referrals for eye exams to get glasses, and if an eye doctor tells you you need one, they probably don't accept your insurance for these types of routine exams.

Patient's name:

Patient's date of birth:

Your name and how you are related to the patient:

Your daytime phone number:

Alternate phone numbers (Remember that if your doctor needs more information, he/she will often be calling during our "lunch" break or after 5 pm):

Your e-mail address (Please include both phone numbers and email address):

 

Name of patient's main insurance:

Insurance ID number:

If this insurance is through a person's job, give the name of that person and his/her date of birth:

 

Name of second insurance, if patient is covered by two different plans:

Second insurance ID number:

If this insurance is through a person's job, give the name of that person and his/her date of birth:

 

Which doctor does the patient see here at Health Associates?

 

Name of person/facility you're going to:
(If you are having a procedure done at a hospital outpatient facility, submit a separate request for the doctor and the hospital referrals):

Address and phone number of doctor/provider/facility:

If you are seeing a doctor or other medical person, what is that person's specialty?

Provider number, if you were given it (a special number assigned by each insurer to each doctor and facility):

If you are being referred to a doctor, have you seen this doctor before? When? Which doctor sent you before?

 

Diagnosis: What is the name of the problem you need the referral for. If you don't know the medical name, describe the problem.
(If the doctor who told you to get the referral gave you some diagnosis code numbers, like "723.18," include those, too.)

Procedure: Is this an office visit, or are you going to have any special procedures done?
List all that will be done by the one person or facility this referral is going to. If you were given procedure code numbers like 99232, list them, too.

Date visit/procedure is scheduled:

Did another doctor refer you? If you were told to get this referral by another doctor, emergency room, etc., who was that and when did you see him/her?

If there will be more than one visit needed, how many?

Any other information you can give us: