Make a Referral to Star Spectrum

Submitting a referral is simple and secure using our HIPAA-compliant online referral form below. This referral form is intended for healthcare providers only. Please complete all required fields and attach any relevant clinical documentation to help us deliver the highest quality care for your patient.

Helping All Children Thrive & Shine

Referral Form

Referring Provider Information

Provider/Clinic Name*

Provider Contact Name*

Phone Number*

Fax Number

Email Address*

Clinic/Practice Address*

Patient Information

Patient First & Last Name*

Date of Birth*

Gender (optional or required, depending on care relevance)

Male Female

Parent/Guardian Name (if applicable)

Parent/Guardian Phone Number (required if child patient)

Parent/Guardian Email

Home Address (optional but useful for scheduling/coverage)

Referral Details

Reason for Referral*

Services Requested*

Evaluation Therapy Consultation

Urgency Level*

Relevant Diagnoses / ICD-10 Codes (Referral must say “Medical Necessity)

Documentation Upload

Attach Clinical Documentation (lab reports, evaluations, progress notes, etc.)*

Max number of files : 1

Max File Upload size of each file : 1 MB

Authorization & Compliance

I confirm that I am a healthcare provider and this referral is submitted with patient/guardian consent in compliance with HIPAA.

*

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Fax: 704-274-3565