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Doctors Entrance

REFERRAL FORMS

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1. Standard Patient Referral Form (See exceptions below: Clinic Referral Forms)
   
   
   1. Specialty Care Outpatient Clinic Appointments:
      
      1. Please check Preferred Location box at the top of the Standard Referral Form.
         
      2. Clinic Schedules

Clinic Referral Forms:

1. Emergency Department Referral Form
   
   
2. Diagnostic Imaging Referral & Order Form
   
   
3. Pulmonary Function Test Request Form
   
   
4. Mental Health & Child Development Referral Form
   1. Insurance Card: Include a fax copy (front and back) of your insurance card.
   2. 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.
   3. Review Period: Allow a 2-week review process before calling to schedule an appointment.
   4. Medical Records: Fax any additional medical records
   5. Complete the entire referral form to avoid any further delays.
   6. 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: liaisons@mail.cho.org
(510) 428-3043

Who do I call with questions?
Call Physician Liaison Services at: 510-428-3043

How to Refer a Patient >

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