Gavini MD

REFERRAL REQUEST
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When requesting a referral please submit your request within five business days. Keep in mind this is just a request as the Insurance Companies or the Doctor may deny your request. With some of the Insurance Companies it takes several days to find out if the referral has been approved or denied. Our office is trying to help our patients avoid having to reschedule their appointments.

Upon receiving your request it will be sent to Dr. Gavini for approval. If for any reason your request isn't approved Dr. Gavini or the staff will contact you before your appointment with the specialist. If you have NOT received a call from our office your referral has been approved by Dr. Gavini as well as your Insurance Company and may procede to your appointment. Please fill out the list of questions to help expedite your request quickly.

Patient's Last Name
Patient's First Name
Patient's Date of Birth	(MM/DD/YYYY)
Patient's Phone Number	(###-###-####)
Patient's Insurance Co.
Which of our Offices is the Patient usually seen?

Date of Appointment	(MM/DD/YYYY)

Type of Specialist
Name of Specialist
Specialist Address
Specialist Phone number	(###-###-####)

Reason for referral (consult/follow up)