Michigan Patient Referral Form

Referring clinician information
Patient Referral Form

Use this form to refer your patient to us.

This form is HIPAA-compliant. Alternatively, you may also fax referrals to us or email.

We aim to reach out to all patient referrals within 1-2 business day of form submission.
Referring clinician name

Your first nameYour last name
Clinician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Clinician Email
So we can contact you with questions or updates about your patient
Practice Name
How would you like to keep updated on your patient's progress?
We can provide updates by fax, email, or phone. We try to proactively update you on your patient's progress and will do our best to honor any requests you have about care coordination or updates. If you don't want updates, please let us know as well.
Patient information
Patient name

Patient's first namePatient's last name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patient contact number
We will attempt to call your patient to schedule an appointment within 1 business day.Format: (000) 000-0000.
Patient email or alternative phone
Used if we can’t reach the patient at their main phone number
Insurance provider
Insurance member ID
Describe the reason for referral (optionally, Please enter any relevant diagnoses, medical history, or other notes here)
(Optional) For insomnia patients, what are their clinician presentations:

Other
(Optional) Please enter any relevant diagnoses, medical history, or other notes here
(Optional) Attach Records

e.g. sleep studies, medication lists or chart notes
Cancelof
(Optional) Anything else you would like to share with us?
Should be Empty:

Referring clinician information

Patient Referral Form

Patient information