Referral For Genetic Consultation With The Greenwood Genetic Center Form printable pdf download

REFERRAL FOR GENETIC CONSULTATION

WITH THE GREENWOOD GENETIC CENTER

Date of Referral: _____________________ Person making referral: _________________________________________

Referring Physician or Agency/Office: __________________________________________________________________

Address: __________________________________ Phone: _____________________ Fax: _____________________

Patient Name: ___________________________________________________________________

Male/Female

(First)

(Middle)

(Last)

Patient’s DOB: ___________________ SS#: _________________________ Interpreter-Yes (Language_________)/No

Parent/Guardian: _________________________________________ Relationship: _____________________________

Address: ___________________________________ City: _________________State: ___________ Zip: __________

Telephone Home: _________________________ Work: _______________________ Cell: ______________________

Primary:

Secondary:

Insurance Company: _____________________________

Policy #: _______________________________________

Policy#: ________________________________________

Authorization #: _________________________________

Authorization #: __________________________________

* Preauthorization number should be obtained before referring SC Medicaid recipients enrolled in Managed Care Plan

REASON FOR REFERRAL: _________________________________________________________________________

_________________________________________________________________________________________________

_____________________________________________

SIGNATURE OF REFERRING PHYSICIAN

Consultation may include laboratory evaluation as recommended by the clinical geneticist. Please send/fax all pertinent

medical records including laboratory results, radiology reports, newborn discharge summaries, eye exams, developmental

records, IQ testing, etc along with this form. If pregnant-include date of delivery.

We will return form when appointment scheduled with patient.

Greenwood Office

Columbia Office

Charleston Office

Greenville Office

Toll free: 888-442-4363

Toll free: 800-679-5390

Toll free: 866-588-4363

Toll free: 866-478-4363

Fax: 864-941-8114

Fax: 803-799-5391

Fax: 843-746-1002

Fax: 864-250-9582

Date of Appointment: ____________________________ Time: ____________________ Clinic: _______________________________

CONFIDENTIALITY NOTICE:

The information contained in this fax message is legally privileged and confidential information. This information is

intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, you are hereby notified that

any dissemination, distribution or copy of this information is strictly prohibited by federal regulation. IF YOU HAVE RECEIVED THIS TRANSMISSION

IN ERROR, PLEASE NOTIFY THE SENDER IMMEDIATELY BY TELEPHONE AT THE NUMBER LISTED ABOVE OR THE GREENWOOD GENETIC

CENTER AT (864) 941-8100.

Referral For Genetic Consultation With The Greenwood Genetic Center Form

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