Referral Requirement Policy

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Some insurance companies require a patient's Primary Care Physician to sign a Referral Form, which is to be presented to the Specialist prior to an office/ home visit. This Referral Form will state the allowed number of visits within a certain specified time limit, and will be dated.

In the event that you do not have a valid Referral Form on deposit in our office and you wish to be examined by the doctor, you are asked to read and sign the following statement.

"I have been informed that I may need a Referral Form from my Primary Care Physician to be on file, prior to being examined. If I do not have such a form on file, and if my insurance company refuses to pay for the examination/ treatment because of this, I agree to be personally and fully responsible for payment."

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