Healthcare Consultation Request

Healthcare Consultation Request

Use this form to request a specialty consultation on behalf of a patient. Complete all applicable sections and attach relevant records. The information provided will be used to schedule and perform the requested consultation and to release medical information to the consulting provider as necessary for treatment, payment, and healthcare operations.

Patient Information

Patient Name:    Date of Birth: 

Primary Phone:    Email: 

Relationship:    Phone: 

Insurance Information

Policy Number:    Group Number: 

Subscriber DOB:    Relationship to Patient: 

Referral and Scheduling

Provider Phone:    Provider Fax (if applicable): 

Routine   Urgent (appointment requested within 7 days)   STAT (immediate attention requested)

Preferred Appointment From:    To: 

Medical History and Attachments

Labs   Imaging (CT/MRI/X-ray)   Operative Reports   Other

Authorization and Acknowledgments

I authorize the release of the patient’s protected health information necessary for the requested consultation and related care. This includes diagnostic results, clinical notes, medication lists, and operative reports. Information disclosed may be re-disclosed by the receiving provider if permitted or required by law.

I acknowledge that: (1) submission of this request does not guarantee an appointment or payment; (2) the patient or responsible party is financially responsible for charges not covered by insurance; and (3) the consulting provider will determine the scope of care and necessary follow-up after evaluation.

By signing below, I acknowledge receipt of the provider’s privacy notice and consent to the release of medical information as described. This authorization expires on the date entered below, unless earlier revoked in writing to the referring provider.

Authorization Expiration Date: 

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