Hearing Care Solutions - Submit Referral for Out of Network Service

Submit Referral for Out of Network Service

Thank you for submitting this out of network referral to Hearing Care Solutions. Please complete the form below and click "Submit Referral". Once submitted, a member of the HCS team will review to confirm patient eligibility and issue your location a provider portal login.

Location Name
and Address

Telephone Number

E-Mail

E-Mail (Confirm)

Tax ID

Provider Name

N.P.I.

Patient Name
and Address

Date of Birth

Gender

Telephone Number

E-Mail Address

Health Plan ID

Appointment Date

Appointment Time