The Asthma Care Center Fax Referral Form printable pdf download

The Asthma Care Center Fax Referral Form

Pediatric And Adult Allergy, P.C.

The Asthma Care Center

Robert Colman, M.D.

1212 Pleasant St – Suite 110

Whitney Molis, M.D.

Des Moines, IA 50309-1490

Tara Federly, M.D.

(515) 244-7229

Fax Referral Form

Please fax this form to (515) 244-7233

DATE: ___________________________

PATIENT NAME: ____________________________________________________________________________

PATIENT DATE OF BIRTH: _________________________________________________________________

PARENT/LEGAL GUARDIAN NAME: _______________________________________________________

CONTACT PHONE NUMBER: _______________________________________________________________

ALTERANATE PHONE NUMBER: ___________________________________________________________

PATIENT INSURANCE: ______________________________________________________________________

REASON FOR REFERRAL: ___________________________________________________________________

_________________________________________________________________________________________________

PROVIDER REQUEST:

[ ] Robert Colman, MD

[ ] Whitney Molis, MD

[ ] Tara Federly, MD

[ ] First Available

REFERRING PROVIDER: ____________________________________________________________________

PERSON SENDING FORM: __________________________________________________________________

REFERRING PHONE NUMBER: _____________________________________________________________

REFERRING FAX NUMBER: _________________________________________________________________

Thank you for choosing Pediatric and Adult Allergy.

Please include patient labs and clinic notes as appropriate. If the patient’s insurance

requires a specialist referral (i.e. Medicaid, Tricare, etc.) please include

the referral information.

When our clinic receives your fax we will call and schedule your patient

and help them prepare for their visit.

(515) 244-7233 



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The Asthma Care Center Fax Referral Form