• Adventist Health Referral Request

    We appreciate the opportunity to care for your patient
  • TO REFER A PATIENT
    Fax: 800-305-0456
    Phone: 877-906-3388
    Email: Referrals@ah.org 
    Direct Messaging: ReferToAH@direct.ah.org

     


    PowerChart Users: AH Referral Admin Pool (Subject line should read "Physician Referral"

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    Pick a Date
  • Referring Provider Information

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  • Patient Information (Please provide copy of patient demographics/face sheet):

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    Pick a Date
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  • Reason For Referral:


  • Documentation Required (Please provide the following with this form):

    • Relevant clinical notes and test results, i.e. history & physical, MRI/CT/X-rays results
    • Insurance Information
    • Authorization information (if required)
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