GASTROINTESTINAL CARE CONSULTANTS, P.A., (GICC,P.A.) - GASTROENTEROLOGY, HEPATOLOGY, GENERAL & ADVANCED ENDOSCOPY

 Please complete entire form and attach copies of prior pertinent clinic notes, endoscopy reports, path reports, labs, imaging results and discharge summaries. We cannot schedule an appointment until this information is received.       
 
REFERRING PHYSICIAN INFORMATION
PHYSICIAN NAME: ____________________________ 
PRACTICE NAME: _____________________________________________
STREET ADDRESS:_____________________________________________ 
______________________________________________________________________________
CITY _______________________________  STATE ___________________
ZIP  __________________    
PHONE: ____________________________     FAX:  _____________________
EMAIL ADDRESS: _____________________________________________    
 
PATIENT INFORMATION                
PLEASE CHOOSE ONE
o   ROUTINE
o   URGENT
LAST NAME: ______________________     FIRST NAME:  __________________________
MIDDLE: __________________________
SEX:  F    M                      DATE OF BIRTH:  __________________   
PRIMARY PHONE: _________________ WORK PHONE:____________________
ADDRESS: ___________________________________________________
CITY: _____________________
STATE:___________
ZIP CODE: _______________
 
INSURANCE INFORMATION
PRIMARY INSURANCE CARRIER: ___________________________________________________
POLICY #: ___________________      GROUP #: __________________   
 EFFECTIVE DATE: _______________
POLICY HOLDER’S RELATIONSHIP TO PATIENT:  SELF   PARENT   SPOUSE   CHILD   OTHER
SECONDARY INSURANCE CARRIER:  INSURANCE:_______________________________________________      
POLICY #:   ____________   GROUP #:  ___________   
EFFECTIVE DATE:    ____________  
 (PLEASE ALSO ENCLOSE COPY OF INSURANCE CARD)
POLICY HOLDER’S RELATIONSHIP TO PATIENT:  SELF   PARENT   SPOUSE   CHILD   OTHER
REFERRAL DATE: ________________________________
AUTHORIZATION #_______________________________________
AMOUNT OF VISITS: ____________________
 
REFERRAL REASON
GERD/Reflux
Colon Cancer Screening
Abdominal Pain
Other Problem:    ______________________________________________________
 
 
 
 
DATE SUBMITTED__________________
 
  
PLEASE CLICK ON THE LINK BELOW:
 
                      REFERRAL FORM  LINK