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You may also fax referrals to 407-612-1595

Provider Referral Disclaimer

By submitting a referral through this website, you confirm that you are authorized to disclose the information provided and that any required patient consents have been obtained in accordance with applicable laws, including HIPAA.

Please submit only the minimum necessary information required for referral purposes. Information submitted through this form is transmitted using secure, encrypted technology and is not stored on the website server. All information is handled in accordance with applicable privacy and security requirements.

Submission of a referral does not guarantee acceptance for treatment, appointment availability, or insurance coverage. Referrals are subject to clinical review and provider availability.

Do not use this form for medical or psychiatric emergencies. If a patient is experiencing an emergency, call 911 or direct the patient to the nearest emergency department immediately.