Physician Referral Form

Fax #: 855-239-8430

Tennessee licensure laws advise that registered dietitians obtain a referral and/or patient documentation from an MD, DO, NP, PA or DC to keep on file, however insurance may or may not be utilized, depending on whether I am in network with your patient. Please fill out the following referral form, or use your own, and fax to Heidi Greenhalgh, MS, RD, LDN at (855) 239- 8430.

Please note the required information needed:

• Medical Diagnosis
• ICD 10 code(s)
• Physician Signature
• Physician NPI #