New York-Presbyterian / Weill Cornell Medicine Patient Referral Portal

Referrer information

Your first name*

Your last name*

Your title/role*

NYP/WCM clinic*

Your phone*

Your email*

Which of the following best describes your referral?**

Primary care patient

Cancer patient

Cancer patient caregiver

Other

Patient information

Patient's first name*

Patient's last name*

Patient's date of birth*

Patient's phone number*

Patient's email*

Patient Street Address*

Patient City*

Patient's State*

Patient's Zip Code*

Patient insurance information:

Patient's Insurance Provider:*

If the insurance provider is not on this list, please select “Insurance Not Listed”

Patient's member ID:*

The member ID can be found on the insurance card. If your member ID is alphanumeric, please include both the letters and numbers you see on your card.

List Insurance Provider Here:*

If not listed, please provide the name of the insurance company

How can we best support your patient?

What is the patient's preferred service delivery method*

Telehealth

In Person

Which level of care are you recommending for the patient?*

Individual Therapy

Intensive Outpatient (IOP)

Psychiatric Evaluation

Medication Management

What describes the patient's current stage in their cancer journey  (if applicable)

Screening/diagnosis

Acute treatment

Long-term treatment

Long-term remission

Other/unsure

Patient diagnoses (if applicable)

Tell us a little more about the patient and their current needs

Clinical documentation (as applicable):

Drop files here or

Max. file size: 5 MB, Max. files: 5.

Please include current medications, medical history, most recent primary care note, most recent oncology note, oncologist contact information, and PHQ9, GAD7 or any other available behavioral health screening inputs.

Location Preference:

Patient's Preferred Location for Services:*

I give or have obtained any necessary consent/authorization prior to disclosing the health information above. The patient is aware of this referral and is expecting Forge Health to contact them directly via phone, voicemail, SMS/text, and email as appropriate.*

Yes

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