Provider Referral Form - Center For Womens Surgery printable pdf download

How to Refer a Patient to Dr. Amy Garcia

1. Complete our referral form, or submit a referral request on any authorized practice referral form.

Please include patient contact information, diagnosis and relevant symptoms.

2. Submit pertinent office notes, radiology reports, pathology reports, operative reports.

3. Instruct your patient to bring a disc of her most recent pelvic ultrasound, CT and/or MRI if she is

being referred for evaluation of uterine bleeding, ovarian cyst/mass or for surgery.

4. Submit all referral documents via fax or mail to the address printed below.

5. Call us to let us know a referral has been sent.

6. We accommodate patients traveling from outside of Albuquerque by arranging consultation and

treatment on the same day or series of days. Please refer your patient to our website for

discounted hotel options.

Procedures Performed In-Office:

While Dr. Garcia performs most procedures without sedation, we offer IV sedation to any patient who needs

or prefers such comfort measures for any reason.



Evaluation of post-menopausal bleeding & heavy bleeding in reproductive aged women.

Any woman with post-menopausal bleeding will be scheduled for in-office hysteroscopy

with Dr. Garcia in 2 weeks or less.



In-office hysteroscopic removal of uterine polyps and small uterine fibroids



In-office hysteroscopy & biopsy, including difficult cases of those with cervical stenosis



In-office hysteroscopic tubal sterilization with Essure, including difficult placements or addressing

complications of previously misplaced coils



In-office endometrial hydrothermal ablation



Placement of intrauterine devices, including complicated IUD placements and removals



Colposcopy and Vaginoscopy



Cystoscopy and Urodynamics

Procedures Performed in the Operating Room (generally out-patient):



Laparoscopic supracervical or total hysterectomy



Laparoscopic myomectomy



Laparoscopic cystectomy (removal of ovary or of ovarian cyst with preservation of ovary)



Laparoscopic oophorectomy (removal of ovary of ovaries)



Suburethral sling placement for incontinence

Insurance:

We are contracted in-network with the following insurances: BCBS, CIGNA, Lovelace Health Plan,

Lovelace Centennial, Lovelace Senior, New Mexico Medicaid, Medicare, Presbyterian Health Plan,

Presbyterian Centennial, Presbyterian Senior, Presbyterian SPN network and Molina. We will do our best

to assist you with coordinating your benefits if we are not in-network with your insurance company.

Caution about UNM Employee BCBS plan and about Intel Employee Presbyterian Health Plan -

these plans consider us OUT OF NETWORK.

201 Cedar SE, Suite 505, Albuquerque, NM 87106 (p) 505.554.3507 (f) 866.881.5131

Updated

5.12.14

Provider Referral Form - Center For Womens Surgery

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