External Referral Form

External Referral Form

I am a Physician's / Physician's Office

Referring Provider First & Last Name*

Clinic Name:*

Zip Code*

Physician/Clinic phone number:*

Phone

What is your specialty?

Please select the service line(s) you are referring to:*

Select

If 'Other,' please specify:

Nutrition Referrals

All Nutrition referrals require a signed CPOE from the referring provider. Please attach below.

Behavioral Health Referrals

If this referral is for a patient in crisis, please do not submit this referral form - contact the service line closest to your area of care.

Additional resources include:

SEARHC’s 24/7 Helpline | 1.877.294.0074

The National Crisis Line | 988 (TTY 711)

If there is an emergency medical condition, call 911 or go to the nearest hospital.

Dental & Orthodontic Referrals

You will be asked below to submit the Patient Medical Record. If you prefer fax, please fax 907-463-6697.

For Orthodontic evaluation, please be sure to include the date of last exam & if patient is caries complete. Thank you.

Dermatology Referrals

If referring a patient for a specific dermatology need, images of the affected area are required.

Images are not required for a full body skin check. Thank you.

Ophthalmology/Optometry Referrals

Please note that the majority of Ophthalmology & Optometry services do not require a referral. Patients can be encouraged to contact their nearest SEARHC Eye Clinic to schedule an appointment - this form does not need to be submitted.

The notable exception is for patients with VA/Tricare insurance; referrals are required for all services.

Providers are welcome to send referrals for urgent medical evaluations, but it is not required.

You will be asked below to submit a Patient Medical Record. Please include prior eye exam notes, including surgery & testing records, if applicable.

If you prefer fax, please use: 907-755-2414.

Radiology Referrals

Please note that physicians submitting referrals relating to radiology procedures must currently have ordering privileges with SEARHC.

If you do not, please do not submit this referral. Ordering privileges can be obtained by emailing a request to mso-searhc@searhc.org.

Please note that a signed order is required. You may upload the order below, under "Patient Medical Record".

If you prefer fax, the radiology/imaging fax is: 907-966-8810.

SEARHC Specialty Referrals

You will be asked below to submit the Patient Medical Record. If you prefer fax, please use the following fax numbers:

For Surgery Clinic - 907-966-8826

For Specialty Clinics - 907-966-8888

Primary Care Services

The majority of Primary Care services at SEARHC do not require a referral. Please do not complete this form.

Instead, have the patient contact SEARHC at 907-463-4040 to schedule an appointment. They can also submit an appointment request online at SEARHC.org.

Type of Visit Requested:*

Select

What is the reason for referral?*

Please include diagnosis, if available.

File Upload*

REMINDER - A referral reason, doctor's signature and a diagnostic code is REQUIRED for most disciplines. Please submit Patient Medical Record and/or signed order, accordingly, including any additional images or files that support/inform the reason for referral.

This ensures minimal patient burden & faster appointment scheduling. Thank you for your help in this.

Drag and drop files here or

Is there an urgent medical need?

Select

If patient has an urgent medical need, please contact the specific service line at the number listed on the website to discuss next avaliable appointment.

Please continue to complete the form & hit submit at bottom.

Please list any additional remarks.

Referred Patient Information

Patient First & Last Name*

Patient DOB*

Patient Gender*

Male

Female

Unspecified

Patient's Home Community:*

Select

Patient Preferred Phone Number:*

Phone

Patient's location preference for treatment (if available)?

I am a Patient or Family Member

Are you an existing SEARHC Patient?*

Select

Please complete our new patient form (linked here). A SEARHC representative will reach out within the next 1-2 business days to discuss appointment availability. You do not need to submit this form.

If you are having an urgent need, please contact the specific service line at the number listed on the website to discuss next available appointment.

Please select the service you are seeking:*

Select

Nutrition Referrals

Please note that nutrition referrals do require a signed order from a physician.

If you do not have one, please do not fill out this form. Contact your primary care physician to seek assistance.

If you have one, please attach it below. Thank you.

Behavioral Health Services

If you are experiencing an urgent need, please contact your local SEARHC office at the number listed here to arrange for care.

Otherwise, a SEARHC representative will reach out within 72 hours to discuss future appointment availability.

Additional resources include:

SEARHC’s 24/7 Helpline | 1.877.294.0074

The National Crisis Line | 988 (TTY 711)

If there is an emergency medical condition, call 911 or go to the nearest hospital.

Primary Care Services

The majority of Primary Care services at SEARHC do not require a referral. Please do not complete this form.

Instead, please contact SEARHC at 907-463-4040 or online to schedule an appointment.

Optometry/Ophthalmology Services

Please note that the majority of Ophthalmology & Optometry services do not require a referral. Patients can contact their nearest SEARHC Eye Care office to make an appointment.

The notable exception is for patients with VA/Tricare insurance - referrals are required for all services.

OBGYN Services

Routine OBGYN care (e.g. pregnancy, routine women's health visits) do not require a referral.

If you have a need for routine care, please do not submit this form. Contact 907-463-4040 to make an appointment or submit an appointment request online.

Is there an urgent medical need?

Select

If patient has an urgent need, please contact the specific service line at the number listed on the website (linked here) to discuss next available appointment.

Please continue to complete the form & hit submit at bottom.

What service are you seeking? Please explain.

Who is submitting this request?*

Select

Please enter the patient's first & last name:*

Please enter the patient's date of birth:*

Please enter the patient's preferred email contact*

If none, write none@none.com

Please enter the patient's preferred contact number:*

Phone

Please select the Patient's home community:*

Select

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