Complete this form to share your clinic's referral requirements.

Question 1 of 10

Reference Code*

Your Full Name*

Your Work Email*

If you have a document with your auth requirements and/or list of accepted insurances, upload it here.

Accepted file types: .pdf, .doc, .docx (max 15MB).

What are common issues with your incoming referral auths?

Can't get in touch with the patient Incorrect patient info (e.g. invalid phone number) Not contracted with the patient's plan or medical group Missing documents Incorrect CPT codes Language barrier Other

What CPT codes do you require on incoming referral auths?

e.g. New patients: 99204 QTY 1. Established patients: 99214 QTY 2.

What services or procedures do you not do?

e.g. Don't treat cataract or retinal conditions.

What is the date of your next available appointment for non-urgent patients?

e.g. 6/18/2026

What common insurances do you not accept?

e.g. Not contracted with Optum and Regal.

When you can’t reach a new patient, what do you do?

e.g. We stop reaching out after 2 phone call attempts.

Complete this form to share your clinic's referral requirements.

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