Patient name:
Suzy Cue
Patient date of
birth:
5/3/90
Your name, if you
are not the patient:
Yvonne Harris-Cue
Your daytime phone
number:
215-555-6677
Alternate phone
numbers (Remember that if your doctor needs more information, he/she
will often be calling during our "lunch" break or after 5
pm):
267-555-9898 mobile
610-555-4444 home (after 6:30)
Your e-mail address
(Please include both phone numbers and email address):
ycue32@lol.com
Name of patient's
main insurance:
PathetiCare HMO
Insurance ID number:
CZ145-872-X5Q
If this insurance
is through a person's job, give the name of that person and his/her
date of birth:
Father: James Cue,
4/12/56
Name of second
insurance, if patient is covered by two different plans:
MinimalChoice HMO
Second insurance
ID number:
xxx-xx-7676-03
If this insurance
is through a person's job, give the name of that person and his/her
date of birth:
Mother Yvonne Cue,
8/14/61
Which doctor does
the patient see here at Health Associates?
Chris/Dr. Daniels
Diagnosis: What
is the name of the problem you need the referral for. If you don't know
the medical name, describe the problem.
If the doctor that told you to get the referral gave you some diagnosis
code numbers, like "723.18," include those, too.
Broken leg (right
tibia)
Procedure: Is this
an office visit, or are you going to have any special procedures done?
List all that will be done by the one person or facility this
referral is going to.
"Complete Fracture
Care"
If you were told
to get this referral by another doctor, emergency room, etc., who was
that and when did you see them?
Dr. Bones in CHOP
emergency room 9/3/03
If a doctor, have
you seen this doctor before? When? Did one of our doctors refer you?
She put on cast in
emergency room.
Name of doctor/provider/facility
this referral is to be made out to
(If you are having a procedure done at a hospital outpatient facility,
submit a separate request for the doctor and the hospital referrals):
Imenda Bones, DO
Address and phone
number of doctor/provider/facility:
1234 34th St., Ste.
405, Philadelphia, PA 19111 215-662-8787
If you are seeing
a doctor or other medical person, what is that person's specialty?
orthopedics
Provider number,
if you were given it (a special number assigned by each insurer to each
doctor and facility):
1245-03
Date visit/procedure
is scheduled:
Two weeks after ER
visit.
If there will be
more than one visit needed, how many?
(She said all visits
and xrays for 90 days are included)
Any other information you can give us:
Please fax
referral to Dr. Bones's office at 215-555-2323 when you have a chance.
Thank you!