Patient Referral

Parent or Guardian Information

Name*

Email*

Relationship to Patient Being Referred*

Patient Information (Child’s Name)

Full Name*

Phone

Street Address*

City*

Zip*

Preferred Language

Reason for Referral *

(Check all that apply & include additional concerns below)

Reason For Referral **

Mental Health
Substance Abuse
Primary Care
Other

Patient Insurance Information

Does the patient have insurance?*

Yes
No

Insurance Company

Policy Number

Member ID

Preferred Location for Service of Patient

Banyan Community Health Center
Lauderdale Lakes
4900 West Oakland Park Blvd.
Lauderdale Lakes, FL 33313
Banyan Community Health Center
Flagler Family Clinic
3733 W. Flagler Street,
Miami, FL 33134
Banyan Community Health Center
Little Havana Campus
3850 W. Flagler Street,
Miami, FL 33134
Banyan Community Health Center
Cutler Bay
10720 Caribbean Blvd., Suite 420
Culter Bay, FL 33189

Please email your completed referral form to: Referrals@banyanhealth.org
or please fax form to: 305-643-7801
For referral questions please call: 305-900-4817

Patient Referral Form

Parent or Guardian Information

Patient Information (Child’s Name)

Reason for Referral *

Patient Insurance Information

Preferred Location for Service of Patient