Referral Request Form

Referral Request Form pen and clipboard

At this point, you should have all the information about your referral in front of you.

Have you verified with your insurance company that you need a referral for the problem that you child has? If not, please stop here and call your insurance company or read the information about your insurance policy.

Have you received approval from your PCP (pediatrician or nurse practitioner)? If not, then stop here and call your PCP at Centre Pediatrics - (617) 735-8585 ext. 7. If yes, then proceed.

Have you made the appointment with the specialist? If not, stop here and call the specialist's office to make an appointment. If yes, then proceed.

Please provide the following information or click here for a printer safe copy of the Referral Request Form that you can fill out and mail or fax to us:

Child's Full Name:
Child's Date of Birth:
Parent's Name:
Home Telephone:	--
Work/Cell Phone:	-- ext:
Email

Insurance Information:

Insurance Company:
Insurance ID:

Appointment Information:

Child's Appointment:
Reason:
Specialist's Name:
Specialist's Provider ID:
Specialist's NPI #:
Specialist's Hospital, Clinic or Office:
Specialist's Address:
City:
State/Province:
Zip/Postal Code:
Specialist's Telephone:	-- ext:
Specialist's Fax Number:	--
Name of PCP who approved this referral:

It takes approximately 5 business days to process your referral paperwork, which includes forwarding the referral to you, to your insurance company and to the specialist. If you have not received such approval within a week of your request, please contact our referral coordinator at 735-8585 ext. 232.