Scholars Community Partner - Request for Patient Referral

For physician/administrator use only.

Community Scholars physicians can request a patient referral into Houston Methodist Hospital for additional services that cannot be provided effectively within the community partner clinic facility he/she is assigned. Please follow all instructions below to ensure the referral process is efficient and supports positive patient outcomes in regards to treatment and billing:

 

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Referral Source

Select the approved organization that the patient is being referred from * Denver Harbor Clinic (Vecino Health Centers) El Centro de Corazon Hope Clinic Legacy Community Health - Montrose San Jose Clinic The Rose Referring physician first name * Referring physician last name * Is the referring physician employed by Houston Methodist? * Yes No Referring physician email * Referring physician phone number * Secondary contact name Secondary contact email Please choose the Community Scholars Program initiating this referral (please select one) * Cardiology Endocrinology Hematology/Oncology Pulmonology Neurology Neuro-Ophthalmology Nephrology Urology Uro-gynecology

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 * Patient address * Patient apartment/unit number Patient city * Patient state * AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Patient ZIP code * Patient mobile phone number Patient email address (if known) Patient Health Insurance type * Uninsured/Self Pay Medicaid Private Insurance Unknown If the patient is 65 years and older, does he/she have Medicare coverage? * Yes No N/A – Patient is less than 65 years old Select all types of Medicare coverage for this patient Part A Part B Part C Part D Patient’s FPL status (%) * Does the patient have Harris Health eligibility (gold card)? (Marking “yes” will not change the approval process for this referral’s case) * Yes No Letter of Eligibility outlining patient’s FPL status (please upload file) *

Requested Service(s)

Please upload the signed doctor’s orders. *

If you do not have the Patient Referral Order form please download the referral form here: Patient Referral 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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