Refugee Support Program - Request for Patient Referral

For physician/administrator use only.

HOPE Clinic can request a patient referral into Houston Methodist Hospital for additional services that cannot be provided effectively within the community clinic. Please follow all instructions below to ensure the referral process is efficient and supports positive patient outcomes regarding treatment and billing:

  • All referrals made to Houston Methodist must be pre-approved by the Office of Community Benefits using this form.
  • Proof of refugee status: Please note we require you to upload a proof of refugee status. Connect with the management team at Hope Clinic to get this information.
  • The department will review your request and get back with you within three business days.
  • Upon review and approval, the Community Benefits Office will respond to the original sender to notify if scheduling can proceed.
  • To protect your privacy, all of our online forms are encrypted.


*denotes required field

Referral Source

Patient Information

Requested Service(s)

If you do not have the 'Refugee Support Patient Referral Order' form, please download the referral form here: Refugee Support Patient Referral Order Form.

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