How to Make a Referral

Faxing a referral request

Please note: We do not take referrals by phone.

To fax your request, complete one of the following forms:

  • Outpatient Referral Form (PDF)
  • The appropriate section's referral form:
  • Your own outpatient referral form. Please ensure that it contains the required referral information listed below.
    • Full name (including maiden name, if known)
    • Date of birth, social security number, or medical record number
    • Current address
    • Current phone number
    • Current insurance information
    • Special needs requirements (interpreter, transportation, preferred day of week for appointment, etc.)
    • Medical history (associated medical conditions, current and ongoing treatments, X-rays, allergies, medications, etc.)
    • Presenting symptoms/diagnosis and duration
    • Physical findings

Fax your request and all pertinent patient notes to the Physician Connection Center:

  • For routine referral visits: 603-676-4080
  • For medically urgent referral visits: 603-640-1909

What happens once I have placed my referral?

Once your request is received, it is logged into our tracking system. A Connection Center representative acts on your behalf to facilitate your request, contacting the appropriate section(s) and following the request through to completion.

Your office is notified of the patient's appointment date, time, and location once it is scheduled. Response times may vary depending on the urgency of your request and the need to communicate with the patient for scheduling purposes.