REFERRING PROVIDER INFORMATION: - Adventist Health



Adventist Health Referral RequestWe appreciate the opportunity to care for your patient. Fax: 800-305-0456 Phone: 877-906-3388Routine Email: Referrals@Urgent PowerChart Users: SH Client Services Admin Pool Subject Line should read: Physician Referral Date:_____________________ No. of Pages:____________ REFERRING PROVIDER INFORMATION:Referred by (MD): ___________________________________Medical Group: Phone: Fax: PCP: Address: City: ZIP: This form completed by:Phone: ___________________________________________________________________________________PATIENT INFORMATION (Please provide copy of patient demographics/face sheet):Last Name:First Name:MI: DOB:Phone: Gender:? Male? FemalePatient Address: City/State/Zip: ____________________________________________________________________________________REASON FOR REFERRAL:Service/Specialty Requested: __________________________Diagnosis/ICD: Physician Requested (if applicable): Service Requested: ? Consultation ? Imaging ? Lab ? 2nd Opinion ? Follow up ? Surgery? Other (please specify): ____________________________________________________________________Reason for Referral: _____________________________________________________________________________________DOCUMENTATION REQUIRED (Please provide the following with this form):Relevant clinical notes and test results, I.e. history & physical, MRI/Ct/X-rays resultsInsurance InformationAuthorization information (if required)Interpreter needed? ? Yes ? No Language: _____________________________________________________ ................
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