For patients and representatives
Request a referral from my PCP
Prepare a request for your primary care team to review, for yourself or someone you represent.
Your primary care clinician decides whether to issue a referral and may ask you to make an appointment. This request does not issue a referral or confirm insurance authorization.
No account or email required. Downloading does not send your request.
Already have your completed PDF?
Upload it in Send a Fax if your primary care team accepts faxed requests. Downloading is free; fax delivery is priced separately and requires your confirmation.
Upload and fax your request →How to use your request
- Choose whether you are requesting for yourself or someone else. Add the patient, primary care team and requested-specialty details.
- Download and review the completed PDF, or fill in the blank PDF in your own reader. You can print either version.
- Give the request to your primary care team using its accepted process. Your entries are not submitted to that team by this website.
- If requesting for someone else, ask the practice what it needs to confirm your role. This form does not establish representative authority or authorize release of records.