Your Trusted Care Partner.

Thank you for choosing Premier Hematology and Oncology as your trusted care partner. We greatly appreciate your confidence in our team to provide exceptional care for your patients. Your referral is invaluable to us, and we are committed to ensuring a seamless and collaborative experience.

Our care team will contact the patient within 24 hours.

Thank you for taking the time to fill out this form and for your continued partnership in delivering outstanding patient care.

Referral Form

Referring Doctor *

Office Phone *

Office Fax *

Patient Information

Patient's First Name *

Patient's Last Name *

Patients Date of Birth *

Patient's Phone Number *

Patient's Address *

Patient's Email *

Patient's Insurance *

Patient's Insurance ID *

Reason for Referral *

Upload a Chart Note

Referral Priority *

Physician Referrals

Refer your patient to Premier Hematology.

Our team reviews all referrals within one business day. We coordinate directly with your office to ensure a seamless transition of care and will send a full report after the patient's visit.

✓Specialist response within 1 business day

✓Full report sent after patient visit

✓Direct fax line available

✓13 locations for patient convenience

Physician Referral Form

Complete all fields. Chart notes can be uploaded or faxed to 718-866-3037.

Referring Physician

Referring Doctor / Practice Name *

Office Phone *

Office Fax

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Patient Phone *

Patient Address

Patient Email

Patient Insurance *

Insurance ID # *

Referral Details

Reason for Referral *

Upload Chart Note (PDF/image)

Referral Priority *