Referral Request/Prior Authorization Form

Note: You will need the NPI number of the physician you have been referred to see. If you don’t have this number, it can be found at the NPI Registry Page.

To request a referral/prior authorization electronically, please click below:
(The Referral/Prior Authorization Form will be located the bottom of the list and labeled Z1.)

Referral/Prior Authorization Request Form

We will contact you as soon as your referral has been processed.
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Referral/Prior Authorization Notes

    For timely processed referrals and prior authorizations please note:

  • We need your correct insurance information on file.
  • We need accurate appointment and specialist information.
  • Referral/Prior Authorization processing may take up to 7 business days.
  • Our preferred referrals are for Winchester IPA and Tufts Medical Center specialist.