Patient Referral Form - Surgical Associates Of North Alabama

 

 

 

 

 

PATIENT   R EFERRAL   F ORM  

 

Referring   P hysician:   _ ___________________________________         D ate:_______________________________________  

Office   C ontact:_________________________________   P hone:__________________       F ax:________________________    

Requested   P hysician:                         W alker                                 B uckner                               S eale                               F igh                         H arney                     F irst   A vailable      

Emergent   ?     Y es       N o  

Patient   N ame:______________________________________________________________________________________  

DOB:___________________Male_____Female_______SS#__________________________________________________  

Phone:____________________________________________________________________________________________  

Address:___________________________________________________________________________________________  

Reason   f or   R eferral:_________________________________________________________________________________  

Primary   I nsurance:   P olicy   n umber,   G roup   n umber,   P olicy   h older   a nd   D OB:  

__________________________________________________________________________________________________  

Secondary   I nsurance:   P olicy   n umber,   G roup   n umber,   P olicy   h older   a nd   D OB:  

__________________________________________________________________________________________________  

Tertiary   I nsurance:   P olicy   n umber,   G roup   n umber,   P olicy   h older   a nd   D OB:  

__________________________________________________________________________________________________  

Any   t esting   p erformed?               Y es                             N o                         * *Please   f ax   p ertinent   o ffice   v isit   b efore   a ppointment**  

If   Y es,   w hat   t est(s):__________________________________________________________________________________      

Date:____________________         F acility:_________________________________________________________________  

  A ppointment   S cheduled   b y:                                             D ate:                                                                           T ime:                                             P t   N otified:               Y es                 N o  

*   I N   O RDER   T O   A VOID   A PPOINTMENT   D ELAYS   P LEASE   F AX   A LL   R ECORDS/RESULTS   W ITH   T HIS   F ORM*  

th

                                                           

  P .   O .   B ox   1 029   1 405   7

  S treet   S W   D ecatur,   A L   3 5602  

                                                                               

Phone   2 56-­‐355-­‐6414     F ax   2 56-­‐355-­‐6646