Clinical team reviewing patient referral documentation

Referral Portal

Refer a Patient to Holistic Heart

Physicians, case managers, discharge planners, and social workers can submit referrals securely online. Our intake team reviews every referral within 2 business hours and contacts you to confirm.

How the Referral Process Works

Submit the Referral

Complete the secure referral form below with patient demographics, diagnosis, insurance information, and requested services.

Intake Review

Our clinical intake team reviews the referral, verifies insurance eligibility, and contacts you within 2 business hours to confirm acceptance.

Care Begins

We coordinate directly with the patient and family to schedule the first visit — typically within 24–48 hours of referral acceptance.

Referring Provider Information

Full Name *

Title / Role

Organization / Facility

Phone Number *

Email Address *

Patient Information

First Name *

Last Name *

Date of Birth *

Patient Phone

Home Address

City

ZIP Code

Clinical Information

Primary Diagnosis *

Secondary Diagnosis

Requested Services *

Select all that apply

Urgency Level

Insurance Information

Insurance / Payment Type *

Member ID / Medicaid ID

Physician Orders

Please provide the ordering physician's information and attach a signed copy of the physician order if available. Orders can also be faxed to our intake team after submission.

Ordering Physician Name

Physician NPI Number

Order Date

Order Type

Attach Signed Physician Order(PDF, JPG, or PNG — max 10 MB)Click to attach order documentor drag and drop here

If you cannot attach the order now, you may fax it to our intake team after submission. Fax number provided upon referral confirmation.

Additional Notes

Fields marked * are required. For STAT referrals, please also call (980) 202-3500 after submitting.

Prefer to Refer by Phone?

Our intake coordinators are available 24 hours a day, 7 days a week.

(980) 202-3500

[email protected]

Quick Links

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Intake Review: Within 2 Business Hours

Our clinical intake team reviews every referral promptly and contacts the referring provider to confirm acceptance and coordinate the first visit.