Physician Outreach - Referral Notice
1. Patient Information
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email
example@example.com
Insurance Plan
2. Referring Provider Information
Referring Provider Name
*
Practice Name
*
Practice Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Fax Number
Practice Email
*
example@example.com
3. Referral Details
Reason for Referral
*
Upload Notes / Records (optional)
Upload a File
Drag and drop files here
Choose a file
Upload the referral note, office note, pathology, labs, photos, or other relevant records.
Cancel
of
Urgency / Appointment Timing
*
ASAP — please contact/schedule as soon as possible
Urgent — within 1 week
Routine — next available appointment
Preferred Location
*
First Available
Garden City
Syosset
Bellerose
Consultation letters will be faxed promptly to the referring provider or primary care physician.
I confirm that I am authorized to submit this referral and accompanying information for purposes of coordinating the patient's care.
*
I confirm
Insurance Notice: Borealis Dermatology accepts most major insurance plans. Network participation varies by plan. If you are unsure of coverage, please submit the referral and our team will verify coverage with the patient.
Send me Borealis Highlights — clinical updates, referral resources and practice news. I can unsubscribe at any time.
Send me Borealis Highlights
GARDEN CITY 400 Garden City Plaza, Suite 111 Garden City, NY 11530
SYOSSET 175 Jericho Turnpike, Suite 320 Syosset, NY 11791
BELLEROSE 251-73 Jericho Turnpike, Suite 401 Bellerose, NY 11426
Submit Referral
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