{"id":792,"date":"2024-07-19T23:29:18","date_gmt":"2024-07-19T18:29:18","guid":{"rendered":"https:\/\/www.wmchealth.org\/?page_id=792"},"modified":"2024-12-11T02:39:38","modified_gmt":"2024-12-10T21:39:38","slug":"refer-a-patient","status":"publish","type":"page","link":"https:\/\/www.wmchealth.org\/about-wmchealth\/refer-a-patient","title":{"rendered":"Refer a Patient"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">At WMCHealth, we are committed to providing your patient with the highest quality of care, with some of the leading providers in several specialties and subspecialties. Our team of skilled physicians and providers are dedicated to delivering compassionate, cutting-edge care for a wide range of medical conditions. As an academic medical center, our access to the latest innovations and research means that we can expertly care for even the most complex cases.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Complete the referral form below to initiate a seamless connection for your patient.<\/p>\n\n\n<style>.wForm form{text-align: left;}<\/style><!-- FORM: HEAD SECTION -->\n    <meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n    <meta name=\"referrer\" content=\"no-referrer-when-downgrade\">\n    <!-- THIS SCRIPT NEEDS TO BE LOADED FIRST BEFORE wforms.js -->\n    <script type=\"text\/javascript\" data-for=\"FA__DOMContentLoadedEventDispatch\" src=\"https:\/\/wmchealthnetwork.tfaforms.net\/js\/FA__DOMContentLoadedEventDispatcher.js?v=52090\" defer><\/script>\n                    <style>\n                    .captcha {\n                        padding-bottom: 1em !important;\n                    }\n                    .wForm .captcha .oneField {\n                        margin: 0;\n                        padding: 0;\n                    }\n                <\/style>\n                <script type=\"text\/javascript\">\n                    \/\/ initialize our variables\n                    var captchaReady = 0;\n                    var wFORMSReady = 0;\n                    var isConditionalSubmitEnabled = false;\n\n                    \/\/ when wForms is loaded call this\n                    var wformsReadyCallback = function () {\n                        \/\/ using this var to denote if wForms is loaded\n                        wFORMSReady = 1;\n                        isConditionalSubmitEnabled = document.getElementById('submit_button').hasAttribute('data-condition');\n                        \/\/ call our recaptcha function which is dependent on both\n                        \/\/ wForms and an async call to google\n                        \/\/ note the meat of this function wont fire until both\n                        \/\/ wFORMSReady = 1 and captchaReady = 1\n                        onloadCallback();\n                    }\n                    var gCaptchaReadyCallback = function() {\n                        \/\/ using this var to denote if captcha is loaded\n                        captchaReady = 1;\n                        isConditionalSubmitEnabled = document.getElementById('submit_button').hasAttribute('data-condition');\n                        \/\/ call our recaptcha function which is dependent on both\n                        \/\/ wForms and an async call to google\n                        \/\/ note the meat of this function wont fire until both\n                        \/\/ wFORMSReady = 1 and captchaReady = 1\n                        onloadCallback();\n                    };\n\n                    \/\/ add event listener to fire when wForms is fully loaded\n                    document.addEventListener(\"wFORMSLoaded\", wformsReadyCallback);\n\n                    var enableSubmitButton = function() {\n                        var submitButton = document.getElementById('submit_button');\n                        var explanation = document.getElementById('disabled-explanation');\n                        var isConditionalSubmitConditionMet = wFORMS.behaviors.condition.isConditionalSubmitConditionMet;\n                        if (\n                            submitButton != null &&\n                            (isConditionalSubmitEnabled && isConditionalSubmitConditionMet) ||\n                            !isConditionalSubmitEnabled\n                        )\n                        {\n                            submitButton.removeAttribute('disabled');\n                            if (explanation != null) {\n                                explanation.style.display = 'none';\n                            }\n                        }\n                    };\n                    var disableSubmitButton = function() {\n                        var submitButton = document.getElementById('submit_button');\n                        var explanation = document.getElementById('disabled-explanation');\n                        if (submitButton != null) {\n                            submitButton.disabled = true;\n                            if (explanation != null) {\n                                explanation.style.display = 'block';\n                            }\n                        }\n                    };\n\n                    \/\/ call this on both captcha async complete and wforms fully\n                    \/\/ initialized since we can't be sure which will complete first\n                    \/\/ and we need both done for this to function just check that they are\n                    \/\/ done to fire the functionality\n                    var onloadCallback = function () {\n                        \/\/ if our captcha is ready (async call completed)\n                        \/\/ and wFORMS is completely loaded then we are ready to add\n                        \/\/ the captcha to the page\n                        if (captchaReady && wFORMSReady) {\n                            \/\/ Prevent both concurrent and sequential executions\n                            if (window.isCreatingCaptcha || window.hasCaptchaRendered) {\n                                return;\n                            }\n                            window.isCreatingCaptcha = true;\n\n                            try {\n                                var submitButton = document.getElementById('submit_button');\n                                var formContainer = submitButton.closest('form') || submitButton.closest('.wFormContainer');\n                                var faCaptcha = null;\n\n                                if (formContainer) {\n                                    faCaptcha = formContainer.querySelector('#google-captcha');\n                                }\n\n                                \/\/ Also check if captcha was appended to 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      height: auto !important;\n                }\n            <\/style><div class=\"\"><div class=\"wForm\" id=\"374-WRPR\" data-language=\"en_US\" dir=\"ltr\">\n<div class=\"codesection\" id=\"code-374\"><\/div>\n<form method=\"post\" action=\"https:\/\/wmchealthnetwork.tfaforms.net\/api_v2\/rest\/workflow\/processor\" class=\"hintsBelow labelsAbove\" id=\"374\">\n<fieldset id=\"tfa_1\" class=\"section\">\n<legend id=\"tfa_1-L\">Referring Provider Details<\/legend>\n<div class=\"oneField field-container-D    \" id=\"tfa_3-D\">\n<label id=\"tfa_3-L\" class=\"label preField reqMark\" for=\"tfa_3\">First name<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_3\" name=\"tfa_3\" value=\"\" title=\"First name\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_4-D\">\n<label id=\"tfa_4-L\" class=\"label preField reqMark\" for=\"tfa_4\">Last name<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_4\" name=\"tfa_4\" value=\"\" title=\"Last name\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_6-D\">\n<label id=\"tfa_6-L\" class=\"label preField reqMark\" for=\"tfa_6\">Specialty<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_6\" name=\"tfa_6\" title=\"Specialty\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_86\" id=\"tfa_86\" class=\"\">Internal Medicine<\/option>\n<option value=\"tfa_87\" id=\"tfa_87\" class=\"\">Family Medicine<\/option>\n<option value=\"tfa_88\" id=\"tfa_88\" class=\"\">Breast Surgery<\/option>\n<option value=\"tfa_89\" id=\"tfa_89\" class=\"\">Cardiothoracic Surgery<\/option>\n<option value=\"tfa_90\" id=\"tfa_90\" class=\"\">Thoracic Surgery<\/option>\n<option value=\"tfa_91\" id=\"tfa_91\" class=\"\">PEDS Cardiac Surgery<\/option>\n<option value=\"tfa_92\" id=\"tfa_92\" class=\"\">Cardiothoracic Surgery (TAVR)<\/option>\n<option value=\"tfa_93\" id=\"tfa_93\" class=\"\">Endocrinology<\/option>\n<option value=\"tfa_94\" id=\"tfa_94\" class=\"\">ENT<\/option>\n<option value=\"tfa_95\" id=\"tfa_95\" class=\"\">Gastroenterology<\/option>\n<option value=\"tfa_96\" id=\"tfa_96\" class=\"\">GYN Oncology &amp; Robotic GYN Surgery<\/option>\n<option value=\"tfa_97\" id=\"tfa_97\" class=\"\">Heart &amp; Vascular<\/option>\n<option value=\"tfa_98\" id=\"tfa_98\" class=\"\">Infectious Disease<\/option>\n<option value=\"tfa_99\" id=\"tfa_99\" class=\"\">Maternal &amp; Fetal Medicine<\/option>\n<option value=\"tfa_100\" id=\"tfa_100\" class=\"\">Medical Genetics<\/option>\n<option value=\"tfa_101\" id=\"tfa_101\" class=\"\">Minimally Invasive Gynecological Surgery<\/option>\n<option value=\"tfa_102\" id=\"tfa_102\" class=\"\">Nephrology<\/option>\n<option value=\"tfa_103\" id=\"tfa_103\" class=\"\">Neurology<\/option>\n<option value=\"tfa_104\" id=\"tfa_104\" class=\"\">Neurosurgery<\/option>\n<option value=\"tfa_105\" id=\"tfa_105\" class=\"\">Oncology &amp; Hematology<\/option>\n<option value=\"tfa_106\" id=\"tfa_106\" class=\"\">OBGYN<\/option>\n<option value=\"tfa_107\" id=\"tfa_107\" class=\"\">Ophthalmology<\/option>\n<option value=\"tfa_108\" id=\"tfa_108\" class=\"\">Orthopedics<\/option>\n<option value=\"tfa_109\" id=\"tfa_109\" class=\"\">Pain Management<\/option>\n<option value=\"tfa_110\" id=\"tfa_110\" class=\"\">Pediatric Neurosurgery<\/option>\n<option value=\"tfa_111\" id=\"tfa_111\" class=\"\">Pediatric Surgery<\/option>\n<option value=\"tfa_112\" id=\"tfa_112\" class=\"\">Pulmonary<\/option>\n<option value=\"tfa_113\" id=\"tfa_113\" class=\"\">Rehabilitation Medicine<\/option>\n<option value=\"tfa_114\" id=\"tfa_114\" class=\"\">Rheumatology &amp; Immunology<\/option>\n<option value=\"tfa_115\" id=\"tfa_115\" class=\"\">Surgery (Burn, Trauma, Colorectal, Surg. Oncology, Plastic, General)<\/option>\n<option value=\"tfa_116\" id=\"tfa_116\" class=\"\">Transplant Center<\/option>\n<option value=\"tfa_117\" id=\"tfa_117\" class=\"\">Urogynecology<\/option>\n<option value=\"tfa_118\" id=\"tfa_118\" class=\"\">Urology<\/option>\n<option value=\"tfa_119\" id=\"tfa_119\" class=\"\">BHI<\/option>\n<option value=\"tfa_120\" id=\"tfa_120\" class=\"\">Ally\/HIV Clinic<\/option>\n<option value=\"tfa_121\" id=\"tfa_121\" class=\"\">Wound Care<\/option>\n<option value=\"tfa_122\" id=\"tfa_122\" class=\"\">Dental OSMFS<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_10-D\">\n<label id=\"tfa_10-L\" class=\"label preField reqMark\" for=\"tfa_10\">Medical facility name<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_10\" name=\"tfa_10\" value=\"\" title=\"Medical facility name\" class=\"validate-alphanum required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_11-D\">\n<label id=\"tfa_11-L\" class=\"label preField reqMark\" for=\"tfa_11\">Phone number<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_11\" name=\"tfa_11\" value=\"\" title=\"Phone number\" class=\"validate-integer required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_12-D\">\n<label id=\"tfa_12-L\" class=\"label preField reqMark\" for=\"tfa_12\">Email address<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_12\" name=\"tfa_12\" value=\"\" title=\"Email address\" class=\"validate-email required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_13-D\">\n<label id=\"tfa_13-L\" class=\"label preField reqMark\" for=\"tfa_13\">Street address<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_13\" name=\"tfa_13\" value=\"\" title=\"Street address\" class=\"validate-alphanum required\"><\/div>\n<\/div>\n<div id=\"tfa_20\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_15-D\">\n<label id=\"tfa_15-L\" class=\"label preField reqMark\" for=\"tfa_15\">State<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_15\" name=\"tfa_15\" title=\"State\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_123\" id=\"tfa_123\" class=\"\">AL<\/option>\n<option value=\"tfa_124\" id=\"tfa_124\" class=\"\">AK<\/option>\n<option value=\"tfa_125\" id=\"tfa_125\" class=\"\">AZ<\/option>\n<option value=\"tfa_126\" id=\"tfa_126\" class=\"\">AR<\/option>\n<option value=\"tfa_127\" id=\"tfa_127\" class=\"\">CA<\/option>\n<option value=\"tfa_128\" id=\"tfa_128\" class=\"\">CO<\/option>\n<option value=\"tfa_129\" id=\"tfa_129\" class=\"\">CT<\/option>\n<option value=\"tfa_130\" id=\"tfa_130\" class=\"\">DE<\/option>\n<option value=\"tfa_131\" id=\"tfa_131\" class=\"\">FL<\/option>\n<option value=\"tfa_132\" id=\"tfa_132\" class=\"\">GA<\/option>\n<option value=\"tfa_133\" id=\"tfa_133\" class=\"\">HI<\/option>\n<option value=\"tfa_134\" id=\"tfa_134\" class=\"\">ID<\/option>\n<option value=\"tfa_135\" id=\"tfa_135\" class=\"\">IL<\/option>\n<option value=\"tfa_136\" id=\"tfa_136\" class=\"\">IN<\/option>\n<option value=\"tfa_137\" id=\"tfa_137\" class=\"\">IA<\/option>\n<option value=\"tfa_138\" id=\"tfa_138\" class=\"\">KS<\/option>\n<option value=\"tfa_139\" id=\"tfa_139\" class=\"\">KY<\/option>\n<option value=\"tfa_140\" id=\"tfa_140\" class=\"\">LA<\/option>\n<option value=\"tfa_141\" id=\"tfa_141\" class=\"\">ME<\/option>\n<option value=\"tfa_142\" id=\"tfa_142\" class=\"\">MD<\/option>\n<option value=\"tfa_143\" id=\"tfa_143\" class=\"\">MA<\/option>\n<option value=\"tfa_144\" id=\"tfa_144\" class=\"\">MI<\/option>\n<option value=\"tfa_145\" id=\"tfa_145\" class=\"\">MN<\/option>\n<option value=\"tfa_146\" id=\"tfa_146\" class=\"\">MS<\/option>\n<option value=\"tfa_147\" id=\"tfa_147\" class=\"\">MO<\/option>\n<option value=\"tfa_148\" id=\"tfa_148\" class=\"\">MT<\/option>\n<option value=\"tfa_149\" id=\"tfa_149\" class=\"\">NE<\/option>\n<option value=\"tfa_150\" id=\"tfa_150\" class=\"\">NV<\/option>\n<option value=\"tfa_151\" id=\"tfa_151\" class=\"\">NH<\/option>\n<option value=\"tfa_152\" id=\"tfa_152\" class=\"\">NJ<\/option>\n<option value=\"tfa_153\" id=\"tfa_153\" class=\"\">NM<\/option>\n<option value=\"tfa_154\" id=\"tfa_154\" class=\"\">NY<\/option>\n<option value=\"tfa_155\" id=\"tfa_155\" class=\"\">NC<\/option>\n<option value=\"tfa_156\" id=\"tfa_156\" class=\"\">ND<\/option>\n<option value=\"tfa_157\" id=\"tfa_157\" class=\"\">OH<\/option>\n<option value=\"tfa_158\" id=\"tfa_158\" class=\"\">OK<\/option>\n<option value=\"tfa_159\" id=\"tfa_159\" class=\"\">OR<\/option>\n<option value=\"tfa_160\" id=\"tfa_160\" class=\"\">PA<\/option>\n<option value=\"tfa_161\" id=\"tfa_161\" class=\"\">RI<\/option>\n<option value=\"tfa_162\" id=\"tfa_162\" class=\"\">SC<\/option>\n<option value=\"tfa_163\" id=\"tfa_163\" class=\"\">SD<\/option>\n<option value=\"tfa_164\" id=\"tfa_164\" class=\"\">TN<\/option>\n<option value=\"tfa_165\" id=\"tfa_165\" class=\"\">TX<\/option>\n<option value=\"tfa_166\" id=\"tfa_166\" class=\"\">UT<\/option>\n<option value=\"tfa_167\" id=\"tfa_167\" class=\"\">VT<\/option>\n<option value=\"tfa_168\" id=\"tfa_168\" class=\"\">VA<\/option>\n<option value=\"tfa_169\" id=\"tfa_169\" class=\"\">WA<\/option>\n<option value=\"tfa_170\" id=\"tfa_170\" class=\"\">WV<\/option>\n<option value=\"tfa_171\" id=\"tfa_171\" class=\"\">WI<\/option>\n<option value=\"tfa_172\" id=\"tfa_172\" class=\"\">WY<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_19-D\">\n<label id=\"tfa_19-L\" class=\"label preField reqMark\" for=\"tfa_19\">ZIP code<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_19\" name=\"tfa_19\" value=\"\" maxlength=\"5\" title=\"ZIP code\" class=\"validate-integer required\"><\/div>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_21-D\">\n<label id=\"tfa_21-L\" class=\"label preField reqMark\" for=\"tfa_21\">NPI<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_21\" name=\"tfa_21\" value=\"\" title=\"NPI\" class=\"required\"><\/div>\n<\/div>\n<\/fieldset>\n<fieldset id=\"tfa_2\" class=\"section\">\n<legend id=\"tfa_2-L\">Patient Details<\/legend>\n<div class=\"oneField field-container-D    \" id=\"tfa_24-D\">\n<label id=\"tfa_24-L\" class=\"label preField reqMark\" for=\"tfa_24\">First Name as displayed on insurance card<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_24\" name=\"tfa_24\" value=\"\" title=\"First Name as displayed on insurance card\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_22-D\">\n<label id=\"tfa_22-L\" class=\"label preField reqMark\" for=\"tfa_22\">Last Name as displayed on insurance card<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_22\" name=\"tfa_22\" value=\"\" title=\"Last Name as displayed on insurance card\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_25-D\">\n<label id=\"tfa_25-L\" class=\"label preField reqMark\" for=\"tfa_25\">Date of birth<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_25\" name=\"tfa_25\" value=\"\" title=\"Date of birth\" class=\"validate-date required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_26-D\">\n<label id=\"tfa_26-L\" class=\"label preField reqMark\" for=\"tfa_26\">Phone number<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_26\" name=\"tfa_26\" value=\"\" title=\"Phone number\" class=\"validate-integer required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_27-D\">\n<label id=\"tfa_27-L\" class=\"label preField \" for=\"tfa_27\">Street address<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_27\" name=\"tfa_27\" value=\"\" title=\"Street address\" class=\"validate-alphanum\"><\/div>\n<\/div>\n<div id=\"tfa_33\" class=\"section inline group\">\n<div class=\"oneField field-container-D    \" id=\"tfa_28-D\">\n<label id=\"tfa_28-L\" class=\"label preField \" for=\"tfa_28\">State<\/label><br><div class=\"inputWrapper\"><select id=\"tfa_28\" name=\"tfa_28\" title=\"State\" class=\"\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_173\" id=\"tfa_173\" class=\"\">AL<\/option>\n<option value=\"tfa_174\" id=\"tfa_174\" class=\"\">AK<\/option>\n<option value=\"tfa_175\" id=\"tfa_175\" class=\"\">AZ<\/option>\n<option value=\"tfa_176\" id=\"tfa_176\" class=\"\">AR<\/option>\n<option value=\"tfa_177\" id=\"tfa_177\" class=\"\">CA<\/option>\n<option value=\"tfa_178\" id=\"tfa_178\" class=\"\">CO<\/option>\n<option value=\"tfa_179\" id=\"tfa_179\" class=\"\">CT<\/option>\n<option value=\"tfa_180\" id=\"tfa_180\" class=\"\">DE<\/option>\n<option value=\"tfa_181\" id=\"tfa_181\" class=\"\">FL<\/option>\n<option value=\"tfa_182\" id=\"tfa_182\" class=\"\">GA<\/option>\n<option value=\"tfa_183\" id=\"tfa_183\" class=\"\">HI<\/option>\n<option value=\"tfa_184\" id=\"tfa_184\" class=\"\">ID<\/option>\n<option value=\"tfa_185\" id=\"tfa_185\" class=\"\">IL<\/option>\n<option value=\"tfa_186\" id=\"tfa_186\" class=\"\">IN<\/option>\n<option value=\"tfa_187\" id=\"tfa_187\" class=\"\">IA<\/option>\n<option value=\"tfa_188\" id=\"tfa_188\" class=\"\">KS<\/option>\n<option value=\"tfa_189\" id=\"tfa_189\" class=\"\">KY<\/option>\n<option value=\"tfa_190\" id=\"tfa_190\" class=\"\">LA<\/option>\n<option value=\"tfa_191\" id=\"tfa_191\" class=\"\">ME<\/option>\n<option value=\"tfa_192\" id=\"tfa_192\" class=\"\">MD<\/option>\n<option value=\"tfa_193\" id=\"tfa_193\" class=\"\">MA<\/option>\n<option value=\"tfa_194\" id=\"tfa_194\" class=\"\">MI<\/option>\n<option value=\"tfa_195\" id=\"tfa_195\" class=\"\">MN<\/option>\n<option value=\"tfa_196\" id=\"tfa_196\" class=\"\">MS<\/option>\n<option value=\"tfa_197\" id=\"tfa_197\" class=\"\">MO<\/option>\n<option value=\"tfa_198\" id=\"tfa_198\" class=\"\">MT<\/option>\n<option value=\"tfa_199\" id=\"tfa_199\" class=\"\">NE<\/option>\n<option value=\"tfa_200\" id=\"tfa_200\" class=\"\">NV<\/option>\n<option value=\"tfa_201\" id=\"tfa_201\" class=\"\">NH<\/option>\n<option value=\"tfa_202\" id=\"tfa_202\" class=\"\">NJ<\/option>\n<option value=\"tfa_203\" id=\"tfa_203\" class=\"\">NM<\/option>\n<option value=\"tfa_204\" id=\"tfa_204\" class=\"\">NY<\/option>\n<option value=\"tfa_205\" id=\"tfa_205\" class=\"\">NC<\/option>\n<option value=\"tfa_206\" id=\"tfa_206\" class=\"\">ND<\/option>\n<option value=\"tfa_207\" id=\"tfa_207\" class=\"\">OH<\/option>\n<option value=\"tfa_208\" id=\"tfa_208\" class=\"\">OK<\/option>\n<option value=\"tfa_209\" id=\"tfa_209\" class=\"\">OR<\/option>\n<option value=\"tfa_210\" id=\"tfa_210\" class=\"\">PA<\/option>\n<option value=\"tfa_211\" id=\"tfa_211\" class=\"\">RI<\/option>\n<option value=\"tfa_212\" id=\"tfa_212\" class=\"\">SC<\/option>\n<option value=\"tfa_213\" id=\"tfa_213\" class=\"\">SD<\/option>\n<option value=\"tfa_214\" id=\"tfa_214\" class=\"\">TN<\/option>\n<option value=\"tfa_215\" id=\"tfa_215\" class=\"\">TX<\/option>\n<option value=\"tfa_216\" id=\"tfa_216\" class=\"\">UT<\/option>\n<option value=\"tfa_217\" id=\"tfa_217\" class=\"\">VT<\/option>\n<option value=\"tfa_218\" id=\"tfa_218\" class=\"\">VA<\/option>\n<option value=\"tfa_219\" id=\"tfa_219\" class=\"\">WA<\/option>\n<option value=\"tfa_220\" id=\"tfa_220\" class=\"\">WV<\/option>\n<option value=\"tfa_221\" id=\"tfa_221\" class=\"\">WI<\/option>\n<option value=\"tfa_222\" id=\"tfa_222\" class=\"\">WY<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_32-D\">\n<label id=\"tfa_32-L\" class=\"label preField \" for=\"tfa_32\">ZIP code<\/label><br><div class=\"inputWrapper\"><input type=\"text\" id=\"tfa_32\" name=\"tfa_32\" value=\"\" maxlength=\"5\" title=\"ZIP code\" class=\"validate-integer\"><\/div>\n<\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_34-D\">\n<label id=\"tfa_34-L\" class=\"label preField reqMark\" for=\"tfa_34\">Specialty service needed?<\/label><br><div class=\"inputWrapper\"><select aria-required=\"true\" id=\"tfa_34\" name=\"tfa_34\" title=\"Specialty service needed?\" class=\"required\"><option value=\"\">Please select...<\/option>\n<option value=\"tfa_44\" id=\"tfa_44\" class=\"\">Breast Surgery<\/option>\n<option value=\"tfa_45\" id=\"tfa_45\" class=\"\">Cardiothoracic Surgery<\/option>\n<option value=\"tfa_46\" id=\"tfa_46\" class=\"\">Thoracic Surgery<\/option>\n<option value=\"tfa_47\" id=\"tfa_47\" class=\"\">PEDS Cardiac Surgery<\/option>\n<option value=\"tfa_48\" id=\"tfa_48\" class=\"\">Cardiothoracic Surgery (TAVR)<\/option>\n<option value=\"tfa_49\" id=\"tfa_49\" class=\"\">Endocrinology<\/option>\n<option value=\"tfa_50\" id=\"tfa_50\" class=\"\">ENT<\/option>\n<option value=\"tfa_51\" id=\"tfa_51\" class=\"\">Gastroenterology<\/option>\n<option value=\"tfa_52\" id=\"tfa_52\" class=\"\">GYN Oncology &amp; Robotic GYN Surgery<\/option>\n<option value=\"tfa_53\" id=\"tfa_53\" class=\"\">Heart &amp; Vascular<\/option>\n<option value=\"tfa_54\" id=\"tfa_54\" class=\"\">Infectious Disease<\/option>\n<option value=\"tfa_55\" id=\"tfa_55\" class=\"\">Maternal &amp; Fetal Medicine<\/option>\n<option value=\"tfa_56\" id=\"tfa_56\" class=\"\">Medical Genetics<\/option>\n<option value=\"tfa_57\" id=\"tfa_57\" class=\"\">Minimally Invasive Gynecological Surgery<\/option>\n<option value=\"tfa_58\" id=\"tfa_58\" class=\"\">Nephrology<\/option>\n<option value=\"tfa_59\" id=\"tfa_59\" class=\"\">Neurology<\/option>\n<option value=\"tfa_60\" id=\"tfa_60\" class=\"\">Neurosurgery<\/option>\n<option value=\"tfa_61\" id=\"tfa_61\" class=\"\">Oncology &amp; Hematology<\/option>\n<option value=\"tfa_62\" id=\"tfa_62\" class=\"\">OBGYN<\/option>\n<option value=\"tfa_63\" id=\"tfa_63\" class=\"\">Ophthalmology<\/option>\n<option value=\"tfa_64\" id=\"tfa_64\" class=\"\">Orthopedics<\/option>\n<option value=\"tfa_65\" id=\"tfa_65\" class=\"\">Pain Management<\/option>\n<option value=\"tfa_66\" id=\"tfa_66\" class=\"\">Pediatric Neurosurgery<\/option>\n<option value=\"tfa_67\" id=\"tfa_67\" class=\"\">Pediatric Surgery<\/option>\n<option value=\"tfa_68\" id=\"tfa_68\" class=\"\">Pulmonary<\/option>\n<option value=\"tfa_69\" id=\"tfa_69\" class=\"\">Rehabilitation Medicine<\/option>\n<option value=\"tfa_70\" id=\"tfa_70\" class=\"\">Rheumatology &amp; Immunology<\/option>\n<option value=\"tfa_71\" id=\"tfa_71\" class=\"\">Surgery (Burn, Trauma, Colorectal, Surg. Oncology, Plastic, General)<\/option>\n<option value=\"tfa_72\" id=\"tfa_72\" class=\"\">Transplant Center<\/option>\n<option value=\"tfa_73\" id=\"tfa_73\" class=\"\">Urogynecology<\/option>\n<option value=\"tfa_74\" id=\"tfa_74\" class=\"\">Urology<\/option>\n<option value=\"tfa_75\" id=\"tfa_75\" class=\"\">BHI<\/option>\n<option value=\"tfa_76\" id=\"tfa_76\" class=\"\">Ally\/HIV Clinic<\/option>\n<option value=\"tfa_77\" id=\"tfa_77\" class=\"\">Wound Care<\/option>\n<option value=\"tfa_78\" id=\"tfa_78\" class=\"\">Dental OSMFS<\/option>\n<option value=\"tfa_82\" id=\"tfa_82\" class=\"\">Transplant<\/option>\n<option value=\"tfa_223\" id=\"tfa_223\" class=\"\">Community Paramedicine - Margaretville Hospital<\/option><\/select><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_38-D\" role=\"radiogroup\" aria-labelledby=\"tfa_38-L\" data-tfa-labelledby=\"-L tfa_38-L\">\n<label id=\"tfa_38-L\" class=\"label preField reqMark\" data-tfa-check-label-for=\"tfa_38\">Requesting a specific provider?<\/label><br><div class=\"inputWrapper\"><span id=\"tfa_38\" class=\"choices vertical required\"><span class=\"oneChoice\"><input type=\"radio\" value=\"tfa_39\" class=\"\" id=\"tfa_39\" name=\"tfa_38\" aria-required=\"true\" data-conditionals=\"#tfa_41\" aria-labelledby=\"tfa_39-L\" data-tfa-labelledby=\"tfa_38-L tfa_39-L\" data-tfa-parent-id=\"tfa_38\"><label class=\"label postField\" id=\"tfa_39-L\" for=\"tfa_39\"><span class=\"input-radio-faux\"><\/span>Yes<\/label><\/span><span class=\"oneChoice\"><input type=\"radio\" value=\"tfa_40\" class=\"\" id=\"tfa_40\" name=\"tfa_38\" aria-required=\"true\" aria-labelledby=\"tfa_40-L\" data-tfa-labelledby=\"tfa_38-L tfa_40-L\" data-tfa-parent-id=\"tfa_38\"><label class=\"label postField\" id=\"tfa_40-L\" for=\"tfa_40\"><span class=\"input-radio-faux\"><\/span>No<\/label><\/span><\/span><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_41-D\">\n<label id=\"tfa_41-L\" class=\"label preField reqMark\" for=\"tfa_41\">Provider's name<\/label><br><div class=\"inputWrapper\"><input aria-required=\"true\" type=\"text\" id=\"tfa_41\" name=\"tfa_41\" value=\"\" data-condition=\"`#tfa_39`\" title=\"Provider's name\" class=\"required\"><\/div>\n<\/div>\n<div class=\"oneField field-container-D    \" id=\"tfa_43-D\">\n<label id=\"tfa_43-L\" class=\"label preField reqMark\" for=\"tfa_43\">Reason for referral<\/label><br><div class=\"inputWrapper\"><textarea aria-required=\"true\" id=\"tfa_43\" name=\"tfa_43\" title=\"Reason for referral\" class=\"required\"><\/textarea><\/div>\n<\/div>\n<\/fieldset>\n<div class=\"actions\" id=\"374-A\" data-contentid=\"submit_button\">\n<div id=\"google-captcha\" style=\"display: none\">\n<br><div class=\"captcha\">\n<div class=\"oneField\">\n<div class=\"g-recaptcha\" id=\"g-recaptcha-render-div\"><\/div>\n<div class=\"g-captcha-error\"><\/div>\n<br>\n<\/div>\n<div class=\"captchaHelp\">reCAPTCHA helps prevent automated form spam.<br>\n<\/div>\n<div id=\"disabled-explanation\" class=\"captchaHelp\" style=\"display: none\">The submit button will be disabled until you complete the CAPTCHA.<\/div>\n<\/div>\n<\/div>\n<input type=\"submit\" data-label=\"Submit\" class=\"primaryAction\" id=\"submit_button\" value=\"Submit\">\n<\/div>\n<div style=\"clear:both\"><\/div>\n<input type=\"hidden\" value=\"711-1746bccc2ac1d0d737b7e65de8cd1553\" name=\"tfa_dbCounters\" id=\"tfa_dbCounters\" autocomplete=\"off\"><input type=\"hidden\" value=\"374\" name=\"tfa_dbFormId\" id=\"tfa_dbFormId\"><input type=\"hidden\" value=\"\" name=\"tfa_dbResponseId\" id=\"tfa_dbResponseId\"><input type=\"hidden\" value=\"7f46d7af80a726c2d9985114fac5dbfb\" name=\"tfa_dbControl\" id=\"tfa_dbControl\"><input type=\"hidden\" value=\"\" name=\"tfa_dbWorkflowSessionUuid\" id=\"tfa_dbWorkflowSessionUuid\"><input type=\"hidden\" value=\"1792005822\" name=\"tfa_dbTimeStarted\" id=\"tfa_dbTimeStarted\" autocomplete=\"off\"><input type=\"hidden\" value=\"11\" name=\"tfa_dbVersionId\" id=\"tfa_dbVersionId\"><input type=\"hidden\" value=\"\" name=\"tfa_switchedoff\" id=\"tfa_switchedoff\">\n<\/form>\n<\/div><\/div><div class=\"wFormFooter\"><p class=\"supportInfo\"><br><\/p><\/div>\n  <p class=\"supportInfo\" >\n      <\/p>\n <\/div>\n\n<script\n    id=\"analytics-collector-script\"\n    type=\"text\/javascript\"\n    src=\"https:\/\/wmchealthnetwork.tfaforms.net\/dist\/analytics\/data-collector.f9f54c12ade21135b7c2.js\"\n    data-customer-id=\"1214\"\n    data-endpoint=\"https:\/\/analytics.formassembly.com\/v1\/traces\"\n><\/script>\n\n\n","protected":false},"excerpt":{"rendered":"<p>At WMCHealth, we are committed to providing your patient with the highest quality of care, with some of the leading providers in several specialties and subspecialties. Our team of skilled physicians and providers are dedicated to delivering compassionate, cutting-edge care for a wide range of medical conditions. As an academic medical center, our access to<a href=\"https:\/\/www.wmchealth.org\/about-wmchealth\/refer-a-patient\">Continue reading <span class=\"sr-only\">&#8220;Refer a Patient&#8221;<\/span><\/a><\/p>\n","protected":false},"author":8,"featured_media":0,"parent":156,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":true,"footnotes":""},"class_list":["post-792","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.9 (Yoast SEO v28.6) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Westchester Medical Center Health Network<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.wmchealth.org\/about-wmchealth\/refer-a-patient\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Refer a Patient\" \/>\n<meta property=\"og:description\" content=\"At WMCHealth, we are committed to providing your patient with the highest quality of care, with some of the leading providers in several specialties and subspecialties. Our team of skilled physicians and providers are dedicated to delivering compassionate, cutting-edge care for a wide range of medical conditions. 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