Infusion Referral Form

Referring MD Information

Patient Information

MM slash DD slash YYYY
Patient's Address

Primary / Secondary Insurance

MM slash DD slash YYYY
MM slash DD slash YYYY

When referring a patient to this office, please include the following (used for Utilization Review and/or insurance verification purposes only) and fax it to (310) 855 9309:

Verification
Drop files here or
Max. file size: 100 MB, Max. files: 10.

    Once this office is in receipt of your request, we will begin the insurance verification process and work to get your patient on the infusion schedule within 5-7 days of the request.

    Consultation requested from one of our physicians:
    This field is for validation purposes and should be left unchanged.
    Wallace & Lee Center

    8750 Wilshire Blvd Suite 210,

    Beverly Hills, CA 90211

    Main Office Phone: (310) 652-0920
    Main Office Fax: (310) 360-4812
    Research Phone: (310) 360-9197
    Research Fax: (310) 360-6219

    Infusion Phone: (310) 360-4806

    Billing Phone: (310) 652-2284

    Billing Fax: (310) 855-9309

    Email Address:

    office@walleemed.com

    Mailing Address

    PO Box 18736,

    Beverly Hills, CA 90209

    Instagram Icon-facebook Linkedin-in Twitter Yelp Google