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• Patient Questionnaire
• Patient Registration
• Specialist Referral Request

• Financial Responsibility
  
• Patient "NO SHOW" Policy
  

Specialist Referral Request

Many insurance companies require that a referral form be completed prior to having specialty care provided, i.e.: seeing a specialist physician, having x-rays or other diagnostic testing done, etc. Please be aware that this may be a requirement of your insurance company. If the referral is not obtained from the insurance company, the patient will be responsible for the full balance of all incurred charges.

Pediatric Associates of Orlando has staff at the Mills office that will obtain these referrals from the insurance companies for you, if our providers feel that additional medical care is necessary for your child. Your are responsible for setting up the appointment with the specialist. Once you have an appointment, please contact our referral staff so that they can proceed with obtaining the referral. You can either call our office or complete the referral form and submit it to us. Depending on your insurance, some referrals can be sent directly to the specialist; however, some paper referrals must be picked-up at our office.

We require two-business days notice to your appointment time in order to obtain the referral.

The referral form must have the following information:

Patient / Parent Information

• Patient's Name
• Patient's Birthday
• Patient's Primary Care Physician
• Parent's Name
• Phone Number
• E-Mail Address
• Primary Office

Specialist and Insurance Information

• Specialist
• Appointment Date and Time
• Reason for Referral
• Insurance Provider
• Insurance Policy Number