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:
- All referrals made to Houston Methodist must be pre-approved by the Office of Community Benefits using this form.
- Letter of Eligibility: Please note we require you to upload a letter of eligibility outlining the patient’s FPL status in the field below. Connect with the host 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.
- To make a Social Determinants of Health request, please click on the Social Determinants of Health Form.
*denotes required field