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Physicians are on the medical staff of Heritage Oaks Hospital, but, with limited exceptions, are independent practitioners who are not employees or agents of Heritage Oaks Hospital. The facility shall not be liable for actions or treatments provided by physicians. Model representations of real patients are shown. Actual patients cannot be divulged due to HIPAA regulations. TRICARE® is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.

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To make a referral, please complete the items below and click “Submit” to send this confidential form to an Assessment and Referral clinician.

You can also fax it to 1-800-217-6218

Patient Name*
First Last
Patient Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Date Format: MM slash DD slash YYYY
Insurance Carrier*
Referred By*
Referral Contact Phone Number*
Diagnosis/Symptoms to be treated/Reason for referring:*
Name
This field is for validation purposes and should be left unchanged.

This form is monitored during regular business hours only.

For immediate assistance, please call our Assessment and Referral line directly at 916-830-2223.

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