For Healthcare Providers

Refer a Patient to MWCSD

Streamline the referral process for your patients with suspected sleep disorders. Our team will contact you to confirm receipt and coordinate next steps within one business day.

50+Years Serving Michigan

4Convenient Locations

3Board-Certified Specialists

Prefer to fax? Send referrals to (517) 887-6734 or call us directly at (517) 887-6733. For STAT referrals, please call directly after submitting this form.

Referring Provider

Your practice information for follow-up coordination

Physician / Provider Name *

Practice / Clinic Name *

Specialty

Preferred Contact Method

Provider Phone *

Provider Fax

Provider Email *

Patient Information

Contact and insurance details for the referred patient

Patient Full Name *

Date of Birth *

Gender

Patient Phone *

Patient Email

Street Address *

City *

State *

ZIP *

Insurance Provider

Insurance ID / Member #

Referral Details

Clinical information to help us prioritize and prepare

Urgency *

Primary Sleep Concern(s) * (select all that apply)

Reason for Referral / Suspected Diagnosis *

Additional Clinical Notes (optional)

Submissions are sent securely to our team at outreach@mwcsd.com and stored in our system for follow-up.

This referral form transmits patient information for care coordination purposes. By submitting, you confirm that you have the patient's consent to share this information with MWCSD in accordance with HIPAA. For urgent needs, please call us directly at (517) 887-6733.