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Patient Referral Request Form

Please complete the form below and a Prime Care Health Solutions team member will contact you to complete your request. For assistance completing this form, please contact us at 214-613-2019.

A Prime Care Health Solutions team member will contact you to complete your request.

Print This Form

Select the program or service you’d like to refer your patient to at Prime Care Health Solutions

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Referring Physician Information

Provide information about the provider requesting the referral
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Field is required!
Your First Name
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NPI Number
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Your Middle Name
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Specialty
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Your Last Name
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Practice Contact Information

Provide information about the contact person for a referral
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Last Name*
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Clinic / Facility Name*
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Phone number
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First Name*
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Clinic / Facility Address
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Fax
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Title
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City*
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Your E-mail Address
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Patient Information

First Name*
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Date of Birth
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State
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Your E-mail Address
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Last Name*
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Your Address
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Preferred Phone number
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Middle Name
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City
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Alternate Phone number
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Appointment Information

Preferred Appointment Date*
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Preferred Appointment Time
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Additional comments about this patient referral
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Primary Care Physician

Name, Address and phone number of primary care provider and all other health care provider or medical doctors*
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Primary Pharmacy

Name, Address and phone number of all pharmacies that provide your medications*
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Payment / Insurance Options

Who will be covering the cost of the service(s) you selected?*
If you are covering the cost by yourself, you will be redirected to a page where you can complete your enrollment and make a payment.
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Your medical insurance information
Please provide your medical insurance information for the selected service(s). Insurance name, primary carrier's name (insured), member ID number, group number, coverage date, effective date and customer service number.
Your medical insurance information
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Field is required!
Your pharmacy insurance information
Please provide your pharmacy insurance information for the selected service(s). Insurance name, primary carrier's name (insured), member ID number, BIN number, group number, coverage date, effective date and customer service number.
Your pharmacy insurance information
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Field is required!
Employer information*
Please provide the following details for your employer: Company name, company address, contact email, phone number.
Employer information*
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