Provider Direct Referral Form

Thank you for trusting Bayou City Breastfeeding with your patient's care. Your referral is essential in providing them with specialized lactation support.

Please complete this form with the patient's contact details. Upon receiving your referral, our process is as follows:

We will promptly reach out to the patient via phone, email, or text.
If insurance information is provided, we will verify coverage and discuss details with the patient.

Your collaboration is invaluable in ensuring timely, personalized care for each family. We appreciate your partnership in enhancing maternal and infant health.

Kindly fill out the information below.

Provider Information

Provider Name

Provider NPI

Practice Name

Parent Information

Patient Information

First Name

Last Name

Preferred Name (If Different)

Email Address

Mobile Phone

Home Phone

Work Phone

Address

Street Address

Adress LIne 2

City

State

Zip

Mother's Date of Birth

Due Date or Delivery Date (If baby already born)

Infant Information

Singleton, Twins or Triplets?

Singleton Twins Triplets

Baby's Name (First and Last)

Twin A's Name (First and Last)

Twin B's Name (First and Last)

Triplet A's Name (First and Last)

Triplet B's Name (First and Last)

Triplet C's Name (First and Last)

Date of Birth

Insurance Information

Insurance Carrier

Will you be providing an electronic referral for insurance? (HMO plans from BCBS and KelseyCare require an electronic referral.)

Yes - Electronic Certified Referral will be provided No - Referral not rquired for this plan Unsure - Contact me if referral is needed

Member ID

Group

Subscriber Name

Subscriber Date of Birth

Employer

Additional Information

Is there a specific IBCLC you are referring your patient to?

Please put any additional information we need to know here.

Your information will be encrypted.