For referral partners

Refer a patient online.

Complete the fillable referral form below. Our referral coordinator will call to verify and confirm all submissions.

Before you submit

1Choose the requested serviceSelect medical care, therapy, Cardiac Rehabilitation (ICR) or behavioral health.

2Complete the patient and provider informationRequired fields help our team review and route the referral correctly.

3Expect a verification callOur referral coordinator will call the referring office to verify the submission and confirm next steps.

Need help?

Call HNR Health at 984-307-4787.

Fax referrals to 984-340-4140.

Online referral

Patient Referral Form

Fields marked with an asterisk (*) are required.

Referring provider information

Provider first name *Provider last name *

Practice or organization *

Office phone *Office fax

Best contact person for verification *

Patient information

Patient first name *Patient last name *

Patient phone *Patient email

Referral detailsRequested service *Reason for referral *

Do not enter diagnoses, treatment information, insurance numbers or other detailed clinical information. Our referral coordinator will obtain necessary information during verification.

Verification required

Our referral coordinator will call to verify and confirm all submissions. Submitting this form does not guarantee acceptance, eligibility, insurance coverage or an appointment.