Fill out the form below to inform the receiving ED of your patient's arrival. Please note that this referral does not guarantee your patient an advanced position in line.
Are you sure that you want to continue without entering the patient’s insurance information?
Entering the patient’s insurance information now will speed processing when the patient arrives at the hospital.
Our system indicates that the patient is younger than 13.
The Children's Online Privacy Protection Act of 1998 (COPPA), a United States federal law, prevents us from collecting the patient’s information.
Unless you indicate below that you are an adult and entering this on behalf of a child, you cannot use this service.
You cannot continue until you have checked the box acknowledging that you are above the age of 18 and
entering this information on behalf of your child, or a child for which you have legal responsibility.