Doctor Referral Portal

Streamlined Referral Process

Our secure online referral system allows you to submit patient referrals quickly and easily. We contact patients within 1 business day to arrange equipment delivery and insurance coordination.

Benefits for Providers:

Track referral status online
Faster equipment delivery to patients
We handle all insurance paperwork
Secure patient data transmission
24/7 submission availability

Referral Form

Doctor Information

First Name *

Last Name *

NPI Number (10-digit) *

Practice Name

Phone

Patient Information

First Name *

Last Name *

Date of Birth

Phone

Diagnosis / ICD-10 Code

Equipment Needed *

Prescription Upload (PDF/JPG/PNG)

Urgency

Notes

I certify this referral is for a patient under my care and I have obtained all necessary consents.

After Submission

You will receive a confirmation email with a tracking number for your referral. Our team will contact the patient within 1 business day to arrange equipment delivery and insurance coordination.

Fax Alternative

Prefer to fax your referral? Send completed forms to our secure fax line at 607-270-2778 or call 607-270-2777 for assistance.

Questions About Referrals?

Our provider relations team is available to assist

Contact Form Call Provider Line