PROVIDERS

Good things happen when you refer people to Good Measures

Help your patients and members get on a healthier path — refer them for extra support for improving their health through food choices, losing weight, slowing chronic disease progression, and improving quality of life.

It's easy to make a referral. Simply complete the HIPAA-compliant secure referral form below or download and use the fax referral form. Good Measures will contact your patient within one business day to schedule an initial consultation.

PHYSICIAN/CLINICIAN INFORMATION

Date of Referral:

NPI#:

Physician/Clinician Name:

Practice/Organization:

Health Plan Type: (check the appropriate box)

Medicare Medicaid Commercial N/A

Physician Phone Number:

Physician Email Address:

PATIENT INFORMATION

Patient Name:

Date of Birth:

Phone Number:

Email:

Diagnosis Codes:

Maternity Referral

Due Date:

First Trimester Weight Goal:

Second Trimester Weight Goal:

Third Trimester Weight Goal:

Notes:

Download Referral Form

Referral questions?

Please contact us at 888-320-1776.

Please fax referrals to 617-507-8576.

We do not accept phone referrals