Florida Oncology Network Physician Form 2026

  • Physician Referral

    Complete the form below and a member of our care team will contact your patient within 24 business hours.

  • Providers who prefer a manual submission may download, print, and fax the FON In-Network Referral Form instead of completing the online form.

  • Referral Urgency (Physician selection is not available when choosing the first available appointment)*

  • Type of Referral

  • Please indicate the specialty for this referral:*
  • Reason for Referral*
  • Insurance Provider*

  • Referring Primary Care Provider/Physician

  • Format: (000) 000-0000.

  • Patient Information

  • Patient Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Patient's Gender*
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  • Select Provider

  • Referring to Physician Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • * Participating specialists for office visit and treatments in the office that do not require pre-certification.

    * Note to receiving Provider/Facility: This referral form is only for medical oncology, hematology and radiation oncology. If you are a non-participating provider, Inpatient Facility or Outpatient Hospital provider an authorization is required for your services. This is not an authorization form and payment is therefore not guaranteed. If you have any questions please call Utilization Management (888) 978-0940.

    * Please do not submit medical records with this request. Once the referral is processed and approved, submit all required medical records directly to the servicing provider.

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