Dermatology Referral Form

For use by referring offices to submit patient details, clinical reason for referral, urgency, and insurance/authorization information.

Before you begin

Please complete this referral form carefully. Do not include sensitive patient files or photos directly in this form. Instead, provide a secure link (e.g. a HIPAA-compliant portal link), or note that records/photos will be sent via fax or secure email after submission.

What to expect

Enter patient demographics and contact information.
Provide referring provider details and clinical reason for referral.
Select urgency level and supply insurance/authorization details.
Review your submission, then submit for processing.

You will receive a confirmation once your referral has been submitted. Our team will review and contact the patient or referring office with next steps.

Secure records handling

Provide a secure link to photos or prior records where prompted (e.g. a portal link or shared drive with access controls).
Alternatively, note in the form that supporting materials will be sent via fax or secure email after submission.
Do not paste unencrypted PHI into free-text fields beyond what is explicitly requested.

I understand this form is for referral submission and I will share records/photos only via secure methods (secure link, fax, or secure email).