Referral Form


General Information on your Referral
CONFIDENTIALITY NOTICE: If faxed materials include Protected Health Information (PHI), these records are CONFIDENTIAL. Premier Infusion Care shall receive authorization from the patient prior to releasing or utilizing PHI for reason other than treatment, payment or healthcare operations. If you are not the intended recipient, you are advised that any disseminations, distribution or copying of this communication is prohibited. Destroy if received in error.
Files must be less than 2 MB.
Allowed file types: pdf.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.