Welcome to Internal Medicine and Primary Care

801 Toll House Ave Suite H-4
Frederick, MD 21701

Ph: +3016989444

Fax: +3016954444

Insurance

Online Referral Request

If you require a referral from your primary care physician to see a specialist You may Either fill out the online referral form or call our office directly.

Please provide the following information:
First Name:
Lat Name:
Birthdate:	(Day)	(Year)
Day Phone Number:
Night Phone Number:
Email:
Primary Care Physician:
Primary Insurance Company:
Primary Insurance ID Number:
Secondary Insurance Company (if any):
Secondary Insurance ID Number:
What doctor, hospital, or healthcare facility have you been referred to:
When is (or was) your appointment scheduled :	(Day)	(Year)
What is the reason (diagnosis) for this referral: