You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Submit button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.
DUE TO THE VOLUME OF OUTSIDE REFERRALS RECEIVED BY JPS HEALTH NETWORK:
- Incomplete referral forms will be denied and discarded upon receipt.
- Copy of insurance card is REQUIRED.
- If you have had any imaging done by another facility please bring the disc with you or complete the form at the bottom of the page.
- HMO and out-of-network insurance WILL NOT be processed without an accompanying authorization.
- Fax this form and ALL attachments to (817) 702-1117 or email to email@example.com.
- The patient access center phone number for referrals and nurse triage is (817) 702-1100. The appointment line phone number is (817) 702-3000.