Referral Request/Prior Authorization Form

Please Read: We use a third party service that allows for these referrals to be sent to us electronically in a secure manner. This service is fully HIPAA compliant and is mainly used for signing forms on-line, which is the reason these links will refer to each form as “a signed document”, even though they may not require a signature.

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 From 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.

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.