For Physicians, Online Patient Referral Form

Referring office information

Provider First Name

Provider Last Name

Provider NPI Number

Practice Name

City

State

ZIP Code

Phone

Fax

Office Contact

Patient First Name

Patient Last Name

Date of Birth

Patient Phone

Marital Status

Gender

Social Security Number

Insurance Type

Insurance Provided By

Diagnosed Date

Address

City

State

ZIP Code

Reason for a requested consultation

I request that CTCA contact my office first before reaching out directly to my patient.

* These fields are required

We will:

Provide an easy and efficient process for your patient referrals
Maintain a dedicated referral phone number
Treat your patient with the highest degree of respect and care
Ensure an efficient and timely insurance verification process
Promptly schedule your patient's appointment
Provide you with helpful access to the physician treating your patient
Swiftly respond to your requests for patient status updates
Collaborate with you to appropriately and deliberately transition patients back to your care