Refer a Patient | ASAP Orthopaedics

New Referral

Please fill out the form to refer your patient. We’ll contact them promptly to coordinate care and schedule an appointment.

Referring Provider Information

Referring Provider Full Name *

Phone Number *

Email Address *

Practice Name *

Patient Information

Patient Full Name *

Patient Date of Birth *

Patient Phone Number *

Patient Email Address *

Secondary Contact (Optional)

If applicable, please share a secondary point of contact:

Name

Phone Number

Clinical Notes

Short Description of the Referral: *

Please upload any relevant documents that will assist our team in preparing for the patient’s care, including the patient’s demographic page and relevant clinical documentation.

Upload Clinical Notes * (PDF, DOCX, or JPG formats accepted)

Note: An insurance referral is different from a provider referral. Some insurances require an insurance referral authorization on file for covered services. The primary care provider (PCP) is responsible for obtaining and sending this insurance referral if required. Please upload this referral if applicable.

Submission Agreement and HIPAA Compliance

By submitting a referral through this platform, you agree to provide accurate and complete information as required. You acknowledge that the referral is submitted via a secure, HIPAA-compliant platform. All personal and medical information shared through this form is protected in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy laws.

You confirm that you have obtained the necessary patient consent to share their information for the purposes of treatment and care coordination. The information provided will be used solely for referral processing and care coordination and will be handled with the highest standards of privacy and security.

By using this service, you agree to comply with all applicable laws and regulations regarding patient privacy and data protection.

I confirm the information is accurate, submitted via a secure HIPAA-compliant platform, patient consent is obtained, and I agree to all privacy laws.