Download Physician Referral Form - Pediatric Gastroenterology

PEDIATRIC GASTROENTEROLOGY ASSOCIATES, P.C.
303 Williams Avenue, Suite 1021, Huntsville Al. 35801 phone: 256.536.3832 fax: 256.536.8829
Request for Clinic Appointment
Dr. preferred: Laney [ ] McClellan [ ] First available [ ] Preferred day/time____________________________________.
PATIENT DEMOGRAPHICS
Demographic sheet may be attached
Patient Name______________________ __________________ ___
Social Security Number___________________________
Last
First
MI
DOB:__________ Age______Sex_______ Address ________________________________________________________________
Street
City
State
Zip
Phone [ ] _______________________ [ ]_______________________ [ ]_______________________.Check preferred contact #.
Home
Work
Cell
Parent/Guardian__________________________________ DOB ___________ Email_____________________________________
INSURANCE INFORMATION If patient has Medicaid, please include a Medicaid referral form with request.
Person responsible for bill/guardian _____________________________________ Relationship to patient____________ DOB______
________________________________________
_______________________________________
_______________
Primary Insurance Company
Primary Policy number
Group Number
____________________________________________________________________________________________________________
Card Holder’s Name
DOB
Address (if different from above)
Social Security #
DIAGNOSIS
Diagnosis Reason for Referral other Health Problems _________________________________________________________________
____________________________________________________________________________________________________________
REFERRING PHYSICIAN INFORMATION
Dr.’s UPIN
Name ______________________________________ Number______________________
Individual NPI
Number ________________________
Phone number________________________ Fax number ________________________ PCP________________________________
Referral number__________________________________
Contact Person/Extension____________________________________
ADDITIONAL INFORMATION
Interpreter Needed? Yes [ ] No [ ]
Language/Hearing/Other Requested_______________________________________________
If Allergies, please list: _________________________________________________________________________________________
If patient has seen other gastroenterologist, who _____________________________________________ when_________________?
CURRRENT MEDICATIONS/HERBAL PRODUCTS/NUTRITIONAL SUPPLEMENTS
Medication Reconciliation Form or copy of assessment in chart may be attached.
Name
Dosage
Frequency
____________________________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
THANK YOU FOR THIS REFERRAL. WE WILL FAX THE APPOINTMENT INFO TO YOU AS SOON AS POSSIBLE SO YOU CAN CONTACT YOUR PATIENT.