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- Standard Patient Referral Form (See exceptions below: Clinic Referral Forms)
- Specialty Care Outpatient Clinic Appointments:
- Please check Preferred Location box at the top of the Standard Referral Form.
- Clinic Schedules
Clinic Referral Forms:
- Emergency Department Referral Form
- Diagnostic Imaging Referral & Order Form
- Pulmonary Function Test Request Form
- Mental Health & Child Development Referral Form
- Insurance Card: Include a fax copy (front and back) of your insurance card.
- Authorization: If insurance authorization is required for Mental health services, the referring provider/primary care physician is required to obtain the first initial authorization in order for us to set up the appointment.
- Review Period: Allow a 2-week review process before calling to schedule an appointment.
- Medical Records: Fax any additional medical records
- Complete the entire referral form to avoid any further delays.
- Questions—please contact us at 510-824-8428.
Patient Information Card:
Download an Appointment Information Card to give all the referral information to your patient.
Referral Directory Requests:
Contact Physician Liaison Services: email@example.com
Who do I call with questions?
Call Physician Liaison Services at: 510-428-3043
How to Refer a Patient >