Provider Referral Pad
Provider Referral Pad
Secure Referral Form For Patient Follow Up
Use this form to refer a patient for an orofacial myofunctional evaluation. We collect only the minimum information needed to contact the patient and understand the referral reason.
HIPAA-Conscious Design
This form does not collect:
- Last name or full name
- Date of birth
- Home address
- Insurance information
- Medical records or detailed clinical notes
Data is transmitted over encrypted HTTPS and emailed directly to our team. No patient data is stored on our servers.
Provider-to-provider referrals for patient care are permitted under HIPAA's Treatment, Payment, and Healthcare Operations (TPO) provisions.