By appointment only, often with no wait time.
646-623-3350
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Allergy Testing
Home
Staff
Services
Insurances
Locations
Press
Referrals
Contact
Allergy Testing
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
*
Date Format: MM slash DD slash YYYY
Phone
*
Email
*
Type of Insurance:
*
Emblem/Hip
Empire/ Blue Cross Blue Shield
Oxford/United Health Care
Patient's ID number:
*
Name of specialist:
*
(FIRST AND LAST NAME)
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:
*
Date Format: 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
