Request a Referral

Please allow three (3) business days for our office to process your request. We accept referral requests Monday through Friday.

Referral requests can be submitted online through the Patient Portal. Please be prepared to complete the following fields:

  • Referral Request (Doctor's Name/Procedure Name)
  • Referral Reason (Diagnosis)
  • Facility or Practice Name
  • Number of Visits
  • Date of Appointment
  • Name of Ordering Provider/Specialty

If you do not have online access, you can download the Referral Request Form below, fill it out completely, and submit it by fax or by visiting your Kennedy Health Alliance primary care office.