Physician Referral
 Phone (817) 514-5252 Fax (817) 514-5246

To make an appointment, you will need to contact your physician for a referral. Your physician's office staff may call (817) 514-5252 for referral information.

 Physician Resources

►Download the Physician Referral form and follow the instructions below for completing it.

1. Please complete the referral form and sign it (physician's signature is required-stamp not allowed.)

2. Along with referral, if available, please fax the following to (817) 514-5246:
  ► Insurance face sheet (copy of card front and back)
  ► Referring doctor's information
    Doctor's full name
    Doctor's office address
    Office telephone number and fax number
    Doctor's UPIN number
  ► Patient Demographics
    Patient's full name, date of birth, social security number
    Patient's current address
    Patient's current home phone number, work number and/ or cell number
    Same for card holder's information
     
  ► Blood Glucose
  ► Hemoglobin A1c
  ► Lipid Profile
  ► Microalbumin (micral)
   

3. For any questions, please call a Diabetes Program Assistant at (817) 514-5252
   
   

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