Referring Physicians

Mon - Fri 8:15-4:00PMSat & Sun - CLOSEDPrimary Care - text (904) 513-3240Pain Management - text (904) 206-71322624 Atlantic BlvdJacksonville, FL 32207

Thank you for the opportunity of caring for your patients. Emed Multispecialty Group welcomes the opportunity to partner with you in caring for your patients. We are always available and committed to serving you and your patients.

Looking to refer a patient? We’ll try to make that easy for you. Please feel free to refer whichever way is convenient for you.

• Call (904) 513-3240 and ask to be connected to the New Patient Coordinators
• Download and fax referral form to (904) 398-7871
• Request appointment online

Used to refer patients for pain management. https://emedmultispecialtygroup.com/pain-management/referring-physicians

"*" indicates required fields

Reason for Appointment*

Name of Physician Requesting Appointment

First Last

Who Should We Contact at Your Office?

First Last

Office Phone

Office Fax Number*

May We Contact Patient Directly to Schedule Appointment

Yes

Patient's Name

First Last

Patient Date of Birth

Patient Primary Phone*

Patient Secondary Phone

Patient Email Address

Best Time to Call During Office Hours? – Start

Best Time to Call During Office Hours? – End

Primary Insurance Company

Authorization Number *If Required*

Patient Address*

Street Address City State ZIP Code

Phone

This field is for validation purposes and should be left unchanged.

Thank you very much for your referral. We review each packet and appropriate referrals will be scheduled for the soonest available intake appointment. If the packet is denied due to inadequate information, you will receive a notice requesting what is still needed.

We have decades of combined experience in primary care! Whether you have a cold or just need a checkup, we’re here for you!

Convenient communication, text:
Primary Care: (904) 513-3240
Pain Management: (904) 206-7132

Physician Online Referral Request Form

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