Referral Form

Who's Eligible? WE EXCEPT ALL INSURANCE!!

• Baltimore City Residence, who have Medicaid MA or MD-CHP
• Excepting ALL Private Insurance

How do I make a referral?

Simply complete the one-page referral form and fax it to our office. Our fax number is (410) 800-2034. You may also feel free to call 410-800-2545 and a representative will assist you.
Or you can download and complete the referral form and submit it below once completed.

[ Download: REFERRAL FORM (doc) | REFERRAL FORM (pdf) ]

Address: 118 E. 25th St. Suite 2 Baltimore, MD 21218

Phone: 410-800-2545 ∙ Fax: 410-800-2034