Patient Referral Form
Please fill out the fields below - we will reach out to you if we require more information to serve the referral. To submit a fax referral, you can access the PDF referral form at seasonhealth.com/referralform and fax to (877) 794-1374.
Patient Information
Patient First Name
*
Patient Last Name
*
Patient ID
*
Unique identifier used by your organization to refer to this patient - oftentimes from your EHR.
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Address
*
Street Address
Address Line 2 (if applicable)
Apartment #, Suite, etc.
City
*
State
*
Zip Code
Patient Email Address
Please provide patient email if available.
Patient Phone Number
*
Reason for Referral
Patient Condition(s)
*
Chronic Condition, Obesity, General Wellness, etc.
Primary Diagnosis Code
*
ICD-10 Code
Additional Patient Information
e.g. allergies, hospital discharge date, food security status, goals, etc.
Patient Insurance Information
All information should match the exact information on the patient's insurance card.
Insurance/Health Plan
*
Member ID #
*
Group #
Subscriber Name
First, Last
Subscriber DOB
-
Month
-
Day
Year
Date
Primary Referrer Information
Please complete this section if you are making this referral on behalf of the patient's physician.
First Name
Last Name
Role at Organization
Nurse, Social Worker, Case Manager, etc.
Phone Number
Fax Number
Email Address
Referring Provider Information
Please fill out the information for the physician referring the patient to Season.
Practice/Health System
*
First Name
*
Last Name
*
Provider Email Address
We'll send an email to confirm we have reached out to the person you referred.
Office Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
*
Office Fax Number
*
Referring Provider Signature
Electronically signed by:
*
Please include provider credentials such as MD, DO, NP, etc.
Electronic Signature Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Referring Provider NPI
*
Submit
Should be Empty: