Privacy Notice*
This form is for referral requests only and is not a secure method for sending private or sensitive health information.

Please do not include or upload protected health information (PHI), medical records, diagnoses, treatment information, Social Security numbers, insurance documents, or other confidential patient information through this form.

Submitting this form does not confirm or complete a referral. A member of the Promise Healthcare team will follow up regarding the referral and provide instructions for securely submitting any necessary patient information or documentation.

If you need assistance with a referral or need to securely provide patient information, please contact Promise Healthcare directly.