Referral Request

Please use this form to request a referral to a specialist's office. We require 7-10 business days to process your request. Referrals will be sent to the specialist's office in time for your appointment. Emergency referrals must be called to the referral office at (717) 397-2738.

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Name of your Provider:
Name of Your Insurance Company: *
Reason for Referral (Diagnosis): *
Who Were You Referred To: *
When Is Your Appointment: *
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General Internal Medicine of Lancaster

2301 Columbia Avenue • Lancaster, PA 17603 • Phone: (717) 397-2738 • Fax: (717) 397-7634

©2017, General Internal Medicine of Lancaster. All Rights Reserved.