Refer a Patient
Steps for Submitting a Telehealth Referral
See our telehealth quick start guide (PDF) »
- Complete a Telehealth Referral Request Form — Fax the form to 866-622-5944 or submit via email along with any documentation outlined in the referral guidelines. For specialties not listed, please provide as much documentation as possible to assist us in securing a one-time consultation.
- Confirmation Call — A telehealth coordinator will call you to schedule your appointment.
- Consultation Instructions — We will provide instructions on how to connect for your consultation. We ask that all sites test the connection prior to the appointment date to ensure good audio/visual quality and review the use of any external telehealth peripherals that might be needed during the consultation.
- Confirm the Appointment — Notify your patient two business days prior to the consultation date.
- Complete Paperwork — Provide your patient with a copy of our Notice of Privacy Practices and fax a signed copy of our Acknowledgement of Receipt form to 866-622-5944 before the consult. Document your patient's verbal consent to participating in a telehealth consultation in your patient's chart/electronic record.
Telehealth Specialties
View our adult specialties and our pediatric specialties, or download our handy PDF version.
Information and Forms
- Allergy and Immunology Patient Questionnaire (PDF)
- Dermatology Referral Request Form (PDF)
- Pediatric Dermatology Evaluation Form (PDF)
- ENT Questionnaire (PDF)
- Pediatric Urology Patient Questionnaire (PDF)
- Pediatric Sleep Questionnaire (PDF)
- Medicare Secondary Payer Questionnaire (Word)
- MIND Patient Questionnaire (PDF)
- MIND Patient Questionnaire in Spanish (PDF)
- Notice of Privacy Practices - English (PDF)
- Notice of Privacy Practices - Spanish (PDF)
- Acknowledgement of Receipt - English (PDF)
- Acknowledgement of Receipt - Spanish (PDF)
- Patient Satisfaction Survey (PDF)
- Provider Satisfaction Survey (PDF)
- Remote Site Guidelines (PDF)
- Telehealth Referral Request Form (PDF)
- Telehealth Quick Start Guide (PDF)