Patient Referrals

Referrals from physicians, case managers, vocational counselors, attorneys, and other insurance professionals are the cornerstone of our practice and help hard workers get in the door for treatment.

Please complete the following form with as much detail as possible, click the submit button, and our patient care coordinators will get right on adding your referral to our system.

Click here to download a PDF version of our referral form.

First Name *

Last Name *

Date of birth *

Address *

Street Address

City

State

Country

Postal code

Phone *

(###) ###-####

Injured Body Part *

Diagnosis Code

Type of Service Requested

Use Ctrl Click to select multiple choices.

Date of Injury

Referral Company or Practice *

Referral Source Email Contact *

Referral Question (s) / Comment (s)

Type of Payment

Self Insurance Provider (if applicable)

Referring Physician

Physician Phone Number

Physician Fax

Claim Manager Last

Claim Manager First

Policy/Claim Number

Claim Manager / Authorizing Agent Phone

Claim Manager / Authorizing Agent Fax

Vocational Counselor Details First

Vocational Counselor Details Last

Vocational Counseling Firm

Vocational Counselor Phone

Vocational Counselor Fax

Attorney/Advocate

Attorney/Advocate Phone

Attorney/Advocate Fax

Upload attachment(s)

Max. file size: 5 MB, Max. files: 3.

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PATIENT REFERRALS

Convivio Health | 16201 25th Ave W Lynnwood, WA 98087 | Email: [email protected] | Phone: (425) 774-9564 | Fax: 425.775.9634

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