Physician Referral Form

Refer your patient to Dr. Bell Razafindrabe using our secure, HIPAA-compliant online form. Submissions are reviewed promptly by our clinical team.

Referral Fax

(620) 792-3804

Office Phone

(620) 792-2991

Address

925 S. Patton Road, Suite B, Great Bend KS 67530

HIPAA Compliant & Secure

Bell Razafindrabe, M.D. FAAPMR · Great Bend, KS

NEW PATIENT REFERRAL

Physician Referral Form

Pain, Spine & Rehab PA

Complete all required fields for timely scheduling. Attach face sheet and relevant imaging or notes to avoid delays.

Referral ID: PSR-20261022-150Need help? (620) 792-2991

Referring Physician

Physician Name

Physician Phone Number

Physician Fax Number— Optional but preferred

Attach Patient Face Sheet or Patient Demographics

Browse Files or drag & drop here

PDF, JPG, PNG, DOC up to 25 MB each · Max 5 files

Please include patient demographics and pertinent medical records

Patient Information

Patient Name

Patient Date of Birth

Patient Phone Number

Referral Details

Medical Service

Specific Physician Requested

Referral Reason— Optional

0/500

This form is transmitted securely. Patient health information (PHI) is handled in accordance with HIPAA regulations.

By submitting, you confirm you have patient consent to share information for treatment purposes. Our team will contact the patient within 1 business day. For urgent referrals, please call directly.

Questions about a referral?

Our clinical team is available Monday through Friday to assist with referral coordination and urgent consultations.

Call (620) 792-2991