The Queen's Health Systems
? Sumodh Kalathil, M.D.? Naoky Tsai, M.D.? Barak Younoszai, D.O.? Leena Hong, PA-C? Isabel Hung Wan, PA-C? Leslie Huddleston, PA-C? Ruby Trujillo, APRN? Ki May Tung, APRN□ Consult □ Fibroscan Only□ Consult and FibroscanReason for Referral:□ HBV□ HCV□ Cirrhosis□ Elevated LFT□ Fatty Liver□ AIH□ PBC□ HCC□ Other: ________________Patient : _____________________________________ DOB : ______________□ Male □ Female(Last Name, First Name, MI)Address: ____________________________________________________________________(Street address, Apt #, City, Zipcode)Home Phone: _______________________Mobile Phone: _______________________ Primary Insurance□ HMSA PPO□ HMSA HMO□ HMSA Quest□ HMSA Akamai□ AlohaCare□ Ohana Medicare□ Ohana Quest□ UHA□ UHC Medicare□ UHC Quest□ Tricare Standard□ Tricare Prime□ HMAA□ Other: __________________________________________Interpreter Required for this Patient: □ No□ YesLanguage: _____________________________ Please include the following items to support the reason for referral:□ Recent lab results (CMP, CBC with Differential & Plts, HBV DNA PCR Quantitative, HBV Surface Antigen, HBVSurface Antibody, HCV RNA PCR Quantitative, and/or HCV Antibody)□ Current progress note□ Recent imaging study (if any)□ Information in CareLink Referring Physician Name _____________________________________Phone: __________________ Address: ___________________________________________________Fax: ____________________ Physician Signature: ________________________________________Date: _____________Mahalo for referring your patient to the Queen’s Liver Center ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- adventist health systems orlando florida
- world health systems ranking
- largest health systems in florida
- queen s english vs american english
- king s english vs queen s english
- health systems around the world
- bronfenbrenner s ecological systems theory
- adventist health systems locations
- largest health systems in us 2020
- largest health systems by state
- valley health systems las vegas
- adventist health systems careers