Referral policy

Your health care insurance, ___________________________________________, requires that you have a valid referral for each and every office visit. Your may also need a separate approval for any procedure you need performed. In general, only very minor procedures can be performed on the initial visit.

Your primary-care physician is the only one who issues a referral. It is advisable to obtain your referral well in advance of your office visit. Attempting get a proper referral on the day of the visit often does not work out.

It is your responsibility to review and verify that you have a properly completed referral and check that the expiration date has not passed. Many insurance plans will not pay for procedures (biopsy, treatment of a skin growth, etc) if performed without a referral and pre-authorization.

If you arrive at the office without a proper referral you should reschedule the visit. If you wish to be seen, you must give us a check for the amount of the visit before being seen. We will hold this for one week. This is to allow you to try and obtain a referral. You still must accept financial responsibility for the visit or any procedure performed.

Remember that you "bought" the referral policy when you purchased your insurance plan over others that don't require referrals.  It is your responsibility to know your policy and to be aware of it’s conditions.

By my signature I affirm I have read and understand this form,

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