Refer a Patient: RX Forms

Caring Hands

Make a Referral with Ease

At Health Care Medical Infusion Specialties, we make it simple for providers to connect their patients to the infusion therapies they need. Our referral forms are organized so you can quickly find the right one, complete it, and fax it with the required documentation to our team.

Fax completed referrals and documentation to 769-233-8051

If you have any questions, our referral support team is here to help at 769-233-8484.

RX Forms

Download, fill out, and fax to 769-233-8051

Allergy and Pulmonology

AutoImmune and Inflammatory

Dermatology

Endocrinology

Gastroenterology and Rheumatology

General Referral Forms

Hematology and Oncology

Immunology and Rare Disease

Infectious Disease

Neurology

Referral Instructions (Reminder)

  1. Select the appropriate referral form.
  2. Complete the form with required patient and provider details.
  3. Fax the form and all corresponding paperwork as indicated.
  4. Our team will confirm receipt and contact you with any questions.
RX Form