Refer a Patient

Please complete and submit this form.

For questions, please call our Referral Center at (877) 333-0122 (Monday-Friday, 8 a.m.- 4 p.m.)

* Indicates required information
REFERRING PHYSICIAN INFORMATION 
Referring Physician Name * 
Referring Physician Office Contact * 
Practice Name 
Phone Number * 
Fax Number 
Email Address * 
PATIENT INFORMATION 
Patient First Name * 
Patient Last Name * 
Patient Birthdate * 
Patient Phone Number * 
Patient Address 
Patient Gender * 

Insurance Name/Plan * 
Subscriber Number * 
Group Number * 
APPOINTMENT OR REFERRAL REQUEST 
Status * 

Specialty 

If Other, please specify:

Diagnosis 
Requested Virginia Mason Provider 
Reason for Referral * 
Comments 
Authentication * 

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Please attach supporting documentation in PDF format only. 
Supporting Documentation: 
(demographics or face sheet, relevant chart notes, medication/allergy list)