Baptist Heart Specialists: Online Referral Request

Baptist Heart Specialists: Online Referral Request Main Content

For your convenience, we have created the online referral request below. Please complete the form and all required (*) fields, then click the "Submit Referral" button at the bottom of the page. You can expect a response from the practice within two business days. Questions? Call 904.202.6700. Please Note: This service is only for NON-emergency referrals. If your patient has a medical emergency, please call 911.

Referral Type

Please select the type of referral you would like to make:

Patient Information

Is this a new patient to our practice?

YesNo

First Name

Middle Initial

Last Name

Email Address

Street Address

City

State	Zip Code
Gender	Date of Birth
Primary Phone Number	Primary Phone Number Type
Secondary Phone Number	Secondary Phone Number Type

Preferred Contact Method

Insurance

Does the patient have primary insurance coverage?

YesNo

Insurance Info

Insurance Provider

Other Insurance

Subscriber Name

Subscriber Date of Birth

Relationship

Policy Number

Insurance Phone Number

Group Number

Diagnosis/Comments

Primary reason for visit

Ordering Physician

Physician First Name:	Physician Last Name:
Office Phone:	Office Fax:

Contact Name

utm

utm_source

utm_medium

utm_campaign

utm_term

utm_content

gclid

Pre-populate Salesforce Fields

AccountID

CaseId

It looks like there was a problem

Try going back and resubmitting the form.

Thank you for your referral

We will attempt to contact the patient on the same business day we received your referral by the contact method you indicated. Once the patient is scheduled, we will send you a confirmation via the fax number you provided on the referral form. At that time, we will ask for the patient's medical records, including any recent labs, EKG, and office notes to be faxed to our office. We will provide you with the appropriate fax number on the confirmation you will receive.

Should you have any questions or need assistance with your referral, please call 904.202.6700.

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