Form for External Referrals

Thank you for choosing Ochsner Health. We welcome the opportunity to partner with you in caring for your patients. Some specialties require an order, clinical notes, and relevant records, so faxing or emailing this information in advance helps expedite the scheduling process and ensures timely care.

Fax Number: 504-842-8416
Email address: clinicconcierge@ochsner.org

Ochsner physicians and providers, please utilize Epic to send in a referral.

Referring MD first name:

Referring MD last name:

City/state:

Phone number:

Fax:

Office contact name (first and last):

Patient Information

First name:

Last name:

Date of birth: (MM/DD/YYYY)

Phone number:

Street address:

City:

State:

Zip code:

Primary insurance:

Contract #:

Group #:

Effective date: (MM/DD/YYYY)

Name on insurance (first and last):

Date of birth: (MM/DD/YYYY)

Secondary insurance:

Contract #:

Group #:

Effective date: (MM/DD/YYYY)

Name on insurance (first and last):

Date of birth: (MM/DD/YYYY)

Diagnosis/Reason for referral:

ICD-10 code:

Specialty requested:

Ochsner Health MD requested:

Notes: