To compare physician referral practices and attitudes regarding hereditary breast cancer by clinical practice location. A self-administered survey of 214 physicians in Ohio's tri-state region. Rural-practice physicians were less likely to have ever referred for an indication of hereditary breast cancer than urban- and suburban-practice physicians combined. Rural-practice physicians reported stronger barriers to referral, including distance, lack of awareness, lack of effective cancer risk reduction, and lack of patient interest. These findings demonstrate a need for increased clinical genetics outreach, physician education, and public awareness of genetic services for hereditary breast cancer in rural areas.