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.
Referring Primary Care Provider/Physician
Primary Care Provider/Referring Physician Name*

First NameLast Name
PCP/Referring Physician Email
example@example.com
PCP/Referring Physician Phone Number*
Please enter a valid phone number.
PCP/Referring Physician Fax Number*
Type of Referral
Please indicate the specialty for this referral:*

Medical OncologyRadiation Oncology
Patient Information
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
Patient Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number*
Please enter a valid phone number.
Patient Seconday Phone Number
Please enter a valid phone number.
Patient's Gender*

MaleFemaleNon-Binary
Insurance Provider*

SimplyFreedomOptimum
Member ID
Referral Urgency (Physician selection is not available when choosing the first available appointment)*

First AvailableRoutineUrgent
Diagnosis Code(s)*
Reason for Referral*

Abnormal test resultAbnormal imaging resultSuspicious findingNew cancer diagnosisChange in existing conditionEvaluation for cancer treatmentEvaluation for radiation treatmentUnexplained lab or blood findingsOngoing symptoms needing specialist reviewMonitoring after previous treatmentSecond opinion requestedTransfer of careReferral requested by patientCare coordination with specialistOther
Select Provider
Please Select a Provider from Below
Referring to Physician Information
Referring to Physician Name*
Please type in Physician First Name to begin search
Office Phone Number*
Please enter a valid phone number.
Fax Phone Number
Please enter a valid phone number.
Reffering to Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referring to Physician Email
example@example.com
* 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.
Please verify that you are human*
Should be Empty:

Physician Referral

Referring Primary Care Provider/Physician

Type of Referral

Patient Information

Select Provider

Referring to Physician Information