RPC Austin Referral Form
This referral form is confidential. In compliance with the Health Portability and Accountability Act "HIPAA" (rule 104-91), please know that communications over the internet are not guaranteed to be secure. There exists a possibility that information you include in this form can be intercepted and read by other parties besides the staff at RPC Austin. Please call us at 512-982-4116 if you prefer to refer a patient by phone.
Referring Provider Name: *
Clinic/Office Name (If Applicable)
Referring Provider Phone Number
Referring Provider Fax Number
Referring Provider Email
What service are you referring your patient for?
Clear selection
Reason for Referral *
Is there a specific provider you are referring your patient to?
Patient Name *
Patient Date of Birth *
MM
/
DD
/
YYYY
Patient Phone Number *
Patient's Email Address
Patient's Current Health Insurance Provider
Submit
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