Referral Request

Referral requests are retrieved from this site several times daily. On weekends, you may want to submit any urgent requests by phone. There is no need to submit multiple requests for the same referral.

We do ask that you give us the courtesy of requesting your referral no less than 3 days prior to your specialist appointment. If you are an Aetna US Healthcare or Keystone Health Plan East member, there is no need to pick up your referral at Hatboro Medical Associates. The information will be sent electronically and will be available to your specialist within 3 days of your request.

Please fill in all information as completely as possible. Then click the SUBMIT button at the bottom of the page.

Patient Information

First Name (required)

Last Name (required)

Middle Initial (required)

Date of Birth (required)

Phone Number

Your Email (required)

Referral Information

Referrer (required)

Specialist's Name (required)

Specialty (required)

Insurance Company (required)

Insurance ID# (required)

Date of Visit (required)

This is an: (required)

Reason for Referral

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Emergencies are handled 24 hours a day, 7 days a week by the on-call physician. Please call (215) 675-1516.