Patient Referral Information Sheet
To expedite your patient’s care, please include ALL of the following information when submitting your referral:
- LEGIBLE COPIES OF INSURANCE CARDS (front & back)
- Patient Demographics & Contact Information
- Most recent office note pertaining to the issue
- Current medication list & surgical history
Additional information is required if your referral pertains to any of the following:
SKIN LESIONS
- All pathology associated with the lesion(s)
PANNICULECTOMY
- Documentation of stable weight (most recent 6 months)
- Documentation of symptoms & attempted conservative treatment Patients must be 18 months post bariatric surgery (if applicable)
BREAST REDUCTION
- Documentation of patient’s current BMI
- Documentation of symptoms & attempted conservative treatment Most recent mammogram (if over age 40)
BREAST RECONSTRUCTION
- All pathology related to diagnosis (including most recent mammogram)
- OP report of mastectomy/lumpectomy (if already performed)
We thank you for your consideration as a partner in your patient care team. If you have any questions, please contact our office directly at (740) 653-5064.
