Referrals Request Form

Please use this secure webform to answer the following questions. Please note, all information provided will be confidential. If this is a medical emergency, call 9-1-1.
Have you seen your PCP for this issue?*

YesNo

Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Reason for your request (medical problem of symptom)*

Are you requesting a new Specialist Referral?*

YesNo
Specialty (ex: orthopedics, cardiology, etc)*
Do you have an appointment already scheduled with the specialist?*

YesNo

Is your appointment scheduled with a Cambridge Health Alliance Specialist/Provider?

YesNo

Please provide the date of your scheduled appointment

MonthDayYear
Date
Who is the appointment with?

First NameLast Name
Providers NPI# (National Provider Identification): *
Please enter 10 digit NPI#
Please provide the Providers phone number:
Please enter a valid phone number.
Please provide the Providers fax number:
Please enter a valid phone number.
Please provide the Providers Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please provide the facility name:

Best phone number to reach you with any questions*
Please enter a valid phone number.
Best time of day to reach you with any questions*

Please provide the date of your scheduled appointment

MonthDayYear
Date
Please provide the name of the Provider and Facility the appointment is scheduled with.
Provider/Facility Name:

Best phone number to reach you with any questions*
Please enter a valid phone number.
Best time of day to reach you with any questions*

Provider Name (if known)

First NameLast Name
Provider Phone Number (if known)
Please enter a valid phone number.
Provider Fax Number (if known)
Please enter a valid phone number.
Provider Address (if known)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please select the date of your appointment. Please allow 7-14 business days to process before an appointment. Please call with any urgent requests.*

MonthDayYear

Thank you for contacting the CHA referral department. Please contact your primary care providers office to discuss your new symptoms so we can best assist you further with your requested referral. *Please note: Insurances require a primary care provider evaluation before referrals can be initiated.

Best phone number to reach you with any questions*
Please enter a valid phone number.
Best time of day to reach you with any questions*
Should be Empty: