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

Referral Source

Select the approved organization that the patient is being referred from * 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 Gastroenterology Hematology/Oncology Nephrology Neurology Neuro-Ophthalmology Orthopedics Pulmonology 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 * Patient ZIP code * Patient mobile phone number Patient email address (if known) Patient Health Insurance type * 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.

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Scholars Community Partner - Request for Patient Referral

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