Make a Referral

If you have a patient who may be a candidate for home infusion services, we encourage you to submit a referral. Upon receipt of your referral form, a Medical Center Infusion Servcies case manager will review your referral and contact you regarding your patient's elligibility for an infusion therapy.

Make a Referral

  • Fill out the appropriate referral form from the list below
  • Print and sign the form
  • Fax the form to 731-660-3549

Referral Forms

Synagis Referral Form

RSV Prevention Center Referral Form

TennCare Synagis Referral Form

Contact Us

We will be happy to answer any questions you have about the referral process.

1061 West Forest Avenue


Jackson, TN 38301


T 731-660-6954 or 800-430-4231


F 731-660-3549

NONDISCRIMINATION NOTICE STATEMENT
West Tennessee Healthcare (WTH) does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, national origin, age, religion, disability, Limited English Proficiency or sex, including discrimination based on gender identity, sexual orientation, sex stereotyping or pregnancy in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by WTH directly or through a contractor or any other entity with which WTH arranges to carry out its programs and activities.

For further information about this policy, contact Amy Garner (731) 541-9914.