Dr. Bennett » Referral Request

Referrals are completed every week on Monday and Thursday mornings. Please use the form below to request a referral for an upcoming appointment - it will be completed on the following Monday or Thursday morning. Referrals will be faxed to the appropriate doctor's office and emailed to the patient. We highly recommend that you bring a copy of your referral to your upcoming appointment.

Please note, we can only make referrals for patients who list Dr. Edward Bennett as their primary doctor (PCP/PMD) with their insurance policy.

Patient's Full Name (as it appears on insurance card)*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
Type of Insurance:*
- Emblem/Hip
- Empire/ Blue Cross Blue Shield
- Oxford/United Health Care
- United Healthcare Community Plan
Patient's ID number:*
Name of specialist:*
(FIRST AND LAST NAME)
Address of the specialist:*
Is this the first time you are seeing this specialist?*
- YES
- NO
The ID Number specialist:*

The ID number is specific to each insurance provider. You should call the specialist that you plan to visit and ask their office staff for the number or you can call you insurance provider.
Fax number of specialist:*
Telephone number of specialist:*
Type of specialist:*

(ie neurologist, cardiologist, dermatologist)
Date of your upcoming appointment:*
MM slash DD slash YYYY
Reason for referral:*

What is the complaint?
How many visits do you think you need at this specialist?*
Please enter a number from 1 to 99.
*Please note that if you have not seen Dr. Edward Bennett within the last 3 months we will be unable to complete your referral request
*Also, It is the patients responsibility to change the PCP/PMD as per insurance guidelines

By appointment only, often with no wait time.

646-623-3350

Referral Request

Press:

Board Certified Internal Medicine &
Board Certified Emergency Medicine

By appointment only, often with no wait time.

646-623-3350

Referral Request

Press:

Board Certified Internal Medicine & Board Certified Emergency Medicine

Board Certified Internal Medicine &
Board Certified Emergency Medicine