Dowloadable  Documents Fax Cover Sheet (Record Request) These documents require Adobe Reader for complete accessibilty and functionality. Click here to download for free if you do not have this software.

Referral Request

In order to properly request a referral, please complete the following form in its entirety. Download the fillable Fax Cover Sheet which must be sent with any and all notes from the date(s) of service requested and Medicaid Eligibility Verification sheet(s) or Medifax applicable to the date(s) of service as well. Due to the inability to receive notes on a consistent basis, any requests for referrals up to six months will not be honored. Please make requests for each individual date of service accordingly.

Because we receive a high volume of faxes, this coversheet is designed especially to assist us in identifying and servicing your request(s) in a timely manner. If the request is made for a previous date of service, any and all notes on the patient(s) are to be included with this fax as well as the Medicaid Eligibility Verfication slip or Medifax. If the request is made for a future date of service, which should also include the Medicaid Eligibiity Verification slip or Medifax, any and all notes on the patient must be faxed to Gyn Care within 24 hours after the visit. All requests must be submitted on an individual basis. Please be aware that requests without this fax coversheet, the Medicaid Eligibiliy Verification slip or Medifax for each requested date of service, and any and all patient notes pertaining to each requested date of service, if applicable, will not be honored.

Facility Contact Information
Facility/Clinic Name:	Required
Address:	Required
City:	Required
State:	Required
Zip Code:	Required
Phone:	() - Required
Fax:	() - Required
Physician's Information (if applicable)
Check this box if not applicable
Physician's First Name:
Physician's Last Name:
This section is not pertaining to the Primary Care Physician (PCP), but only if there is a specific physician this referral needs to be made for. If there is none, please check Not Applicable.
Requestor's Information (if applicable)
Check this box if not applicable
First Name:
Middle Name:
Last Name:
Email:
Patient's Contact Information
First Name:	Required
Middle Name:
Last Name:	Required
SS#:	Required
Medicaid ID#:	Required
Birth Date:	Month 1 2 3 4 5 6 7 8 9 10 11 12	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Year 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Address:	Required
City:	Required
State:	Required
Zip:	Required
Phone:	( ) - Required
Date(s) of Service:	From: Required
	Month 1 2 3 4 5 6 7 8 9 10 11 12	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Year 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
	To: Required
	Month 1 2 3 4 5 6 7 8 9 10 11 12	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31	Year 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Diagnosis/Suspected Condition:
Required

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