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.
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Referral Source

Referring physician first name * Referring physician last name * Referring physician email * Referring physician phone number * Secondary contact name Secondary contact email What is the specialty this patient is being referred for? (Only one specialty is allowed.) * Does the patient have additional specialty care needs? * Yes No

Please list additional (secondary) specialty care needed for this patient. (Optional)

Patient Information

Please enter patient’s name exactly as shown on official identification. Patient first name * Patient middle name Patient last name * Patient gender * Female Male Other Patient date of birth * Country of origin * Languages Spoken (List all) * Date of entry into USA * Patient address * Patient apartment/unit number Patient city * Patient state * Patient Postal Code * Patient mobile phone number Patient email address Patient Case Manager Name Patient Case Manager Phone Number Patient Case Manager Email Does the patient have Harris Health eligibility (gold card)? (Marking “yes” will not change the approval process for this referral’s case) * Yes No Proof of Refugee Status (please upload file) *

Requested Service(s)

Please upload the signed doctor’s orders. *

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

Reason for referral * Ordering physician, if different than referring physician (first and last name) Diagnosis/Chief complaint * Procedure(s) and/or service(s) being requested * Please add the CPT code(s) if known Are there medical records that need to be sent pertaining to this referral? * Yes No

Medical records and/or additional documentation. (Please upload file. Limit upload to 4 pages.) * If medical records exceed the 4 page limit, please fax the records to 713-799-9588.

Additional comments

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Refugee Support Program - Request for Patient Referral

Referral Source

Patient Information

Requested Service(s)

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