Insurance Approval/Referral for HMO Blue Cross Patients

Complete and we will fax the request to your primary care physician.

RHODE ISLAND EAR, NOSE & THROAT PHYSICIANS INC.

Patient Name

Date of Birth

Reason for Visit

Cell Phone

Email address

Insurance Member ID

Primary Care Physician

Fax

You can upload the insurance approval/referral here. If you are unable to upload the documents below, we can scan them during your appointment.

Add file

Please upload a file

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