Refer a Patient | Prime Care Health Solutions

Please complete the form below and a Prime Care Health Solutions team member will contact you to complete your request. For assistance completing this form, please contact us at 214-613-2019.

Date *

Referral ID

Referring Provider Information

Provider First Name *

Provider Last Name *

NPI Number

Practice/Facility Name *

Phone *

Fax

Email *

Patient Information

Patient First Name *

Patient Middle Name

Patient Last Name *

Date of Birth *

Gender *

Phone *

Address

Patient Insurance Information

Medical Insurance Provider

Policy/Group Number

Pharmacy Insurance Provider

RX Bin / PCN

Service Requested *

Diabetes Prevention Program (DPP)

Disease Management

Medication Review / Reconciliation

Genetic Testing (PGx, NGx)

COVID-19 Test

Drug Screen

Biometric Screening

Other

Clinical Information

Diagnosis / Reason for Referral *

Current Medications

Allergies

Additional Notes / Special Instructions

Provider Signature

Provider Signature (Type Full Name) *

Date *

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Patient Referral Request Form

Patient Referral Request Form