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 one business day.
  • 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

Patient Contact Information

Requested Service(s)

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