If you would like to print out a referral sheet to send along with your records, click here to download the file.
If you would like to send a referral through this website, please fill out the relevant fields below.
You may also send us medical records or other files through this secured page. Under FILE UPLOAD, you may add up to 10 files (10 MB size limit per file).
When you are finished, click the Upload button to submit the referral.
NOTE: Not all fields must be filled in order to submit a file but please make note of your name, the claimant’s name and your email address at a minimum.
If you have any questions about your referral, please call us at (410) 740-3084.
[contact-form 2 “Online Referral”]