Provider Referral Form

Accepting BCBS · UHC · Aetna · Cigna | Telehealth available across IL, MA & MD

Happy Gut Nutrition

Provider Referral Form — connect your patients with expert nutrition care in just a few clicks.

HIPAA-Compliant Submission — This form is transmitted securely. Please include only the minimum necessary information to facilitate the referral. No physician referral is required for MNT services in most states.

Something went wrong. Please try again or fax your referral to (773) 269-3318.

Referring Provider Information

Provider Name *

Credentials / Specialty

Practice Name *

NPI Number

Phone *

Fax

Best Email for Follow-Up

Patient Information

Patient First Name *

Patient Last Name *

Date of Birth *

Patient Phone *

Patient Email

Insurance Plan *

Reason for Referral

Primary Condition(s) — select all that apply

Diabetes / Prediabetes
Cardiovascular / Lipids
GI / Digestive Issues
Autoimmune / Inflammation
Weight Management
GLP-1 Therapy Support
Thyroid / Hormonal
Eating Behavior Support
Renal / CKD
General Wellness

ICD-10 Code(s)

Relevant Clinical Notes

Preferred Visit Modality

We will contact the patient within 24 hours of receiving this referral.
A summary of nutrition care will be sent back to your office after each visit.

Referral Received!

Thank you — we’ll reach out to your patient within 24 hours and keep you updated on their progress.

Prefer to refer another way?

Fax: (773) 269-3318

Email: referrals@happy-gut-nutrition.com

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This form collects the minimum necessary PHI to coordinate patient care. All data is transmitted and stored in compliance with HIPAA regulations.

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