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

Is the referring physician employed by Houston Methodist? *
Please choose the Community Scholars Program initiating this referral (please select one) *

Patient Information

Patient gender *
If the patient is 65 years and older, does he/she have Medicare coverage? *
Select all types of Medicare coverage for this patient
Does the patient have Harris Health eligibility (gold card)? (Marking “yes” will not change the approval process for this referral’s case) *

Requested Service(s)

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

Are there medical records that need to be sent pertaining to this referral? *

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