Please feel free to print this form and fax this referral request to 212-571-7465. Please make sure as much of the form is filled out in order for us to process the referral as quickly as possible. If you prefer to e-mail the request please click below. Please allow time for your doctor to review your records and approve the request. Thank you in advance for your patience.

Full Name:
Phone Number:
E-Mail Address:
Today's Date:
Date of Birth:
Name of Primary Insurance Carrier:
Policy Number:
Primary Care Physician (PCP) at NY Downtown Medical Associates:

Your Referral Is For a Provider or Procedure in What Specialty?:
Specific Provider Name (if known and is a participating physician):
Specific Provider's Phone Number (if known):
Reason for Referral:

Other Notes: