Scott & White in Temple Patient Referral Network (PRN) Request

Scott & White strives to ensure prompt management of all patients and timely responses to our referring physicians. Please complete the form below and submit. You will receive a confirmation receipt to your request within one business day. If this is an urgent request, please call the PRN office at 800-792-3368 or 254-724-2218. Referral requests are handled via a secure server.

Thank you for choosing Scott & White.


Referring Physician Information
Items with (*) are required to process your request.

Referring Provider  
Last Name*:
First Name*:
Middle Name:
Office Address*:
UPIN Number:
NPI Number:
Credentials (M.D., etc)*:
Clinic Contact Person*:
Contact Phone*:
Clinic Fax Number*:
How would you like to receive patient information?*: Fax Mail

Patient Information

Last Name*:
First Name*:
Middle Name:
Scott & White MRN:
(If available)
Date of Birth*:
Social Security Number*:
Phone Number (home)*:
Phone Number (work):

Health Insurance

Health Insurance Plan(s)*: Insurance
Health Insurance Company
Authorization Number (if required)
Insurance Indentification Number
Card Holder Name
Card Holder Date of Birth
Social Security Number
If different from patient

Appointment Request

Physician: Find a Doctor
Specialty Preference *:
Appointment Needed*:
If this is an urgent request, call the PRN office at 254-724-2218 or 800-792-3368
Reason for Appointment*:

Additional Information

Please fax an enlarged copy of the patients insurance card,
H&P dictations, lab results, and x-ray results to 254-724-7560.
Please note on the coversheet that the referral form was sent via the Internet.
We ask that film be hand carried by the patient at the time of visit.

For e-mail confirmation of this form please enter your e-mail address:
(For more than one entry, please enter a comma between each e-mail address)