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For Referring Providers

Thank you for the trust you place in our practice . Please find the Consultation (referral)  form below or feel free you use your  EMR (see guidelines below)

We respectfully request when you send a referral that you would please fax and  include the following ( if available):

1. A specific clinical question you would like to be addressed including a brief summary of the most relevant clinical information as it relates to your overall care plan , i.e. history, tests, and treatments

2. The type of referral, either:

____Surgical, management only

____Management of a focused gyn problem

____Opinion/recommendation/second opinion only

____Take over women’s health care needs

3. Urgency: (Choose one)

 _______Urgent: ( 1-2 days) -for appts that need to be seen in <48 hours please call the office so there can be a direct phone triage call with Dr Motyka. Minimally provide written justification for urgency

 _______Subacute (1-2 weeks)

_______Routine 2-8 weeks

4. Demographics including name, contact information, and insurance information

5. Notification if the patient requires approval from your practice for additional tests, treatments, or referrals

6. Core medical data on patient including: Active problem list , Updated medication list, Medical allergies, Significant medical and surgical history ,  Significant family history , Significant behavioral habits/social history not previously specified, List of providers (care team)


Please make sure the patient is made aware of and is in agreement with reason for referral, is provided with expectations for events and outcomes of referral, and is in agreement with the selection of our practice.

We can provide a referral form for you to use or you can send this info via your EMR.

Thank you for the trust you place in For Women, PA.  We appreciate any feedback you might have on what would make the referral process easier for you and your practice staff.

Consultation request form
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