Your Referral Guide to St. Mary's Services - St. Mary's Medical Center

Your Referral Guide to St. Mary’s Services
At St. Mary’s, we appreciate the ever changing world of healthcare and value efficient,
time‐saving tools. We have created this document as a reference for your office. You may also
obtain the most current information at the following link: www.stmarys.org/referral
For Further Information, Please Contact:
Amy Susott, RRT, MPSA
Director, Strategic Development
Phone: 812.485.6983 Cell: 812.455.0804
alsusott@stmarys.org
Julie Morrow
Senior Business Development
Coordinator, Strategic Development
Phone: 812.485.7095
Julie.Morrow@stmarys.org
Shannon Earhart
Senior Coordinator, Strategic Development
Phone: 812.485.4972
Shannon.Earhart@stmarys.org
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Table of Contents:
Center For Children ...................................................................................................................................................................... 3
Center for Children Referral Form .................................................................................................................................. 7
Pediatric Sleep Referral Form ......................................................................................................................................... 8
Imaging/Radiology Services ......................................................................................................................................................... 3
Joslin Diabetes Center .................................................................................................................................................................. 3
Joslin Diabetes Center Referral Form .............................................................................................................................. 9
Lab Services ................................................................................................................................................................................. 3
Maternal‐Fetal Medicine and Genetics Center ............................................................................................................................. 3
Maternal Fetal Medicine and Genetics Center Referral Form ........................................................................................10
Medical Equipment (DME) ........................................................................................................................................................... 4
Home Oxygen Order Form ............................................................................................................................................11
Nebulizer Order Form ....................................................................................................................................................12
Letter of Medical Necessity‐Matriarch ..........................................................................................................................13
Letter of Medical Necessity‐Rachis ................................................................................................................................14
Nephrology Associates ................................................................................................................................................................. 4
Nephrology Referral Form .............................................................................................................................................15
OB/GYN ....................................................................................................................................................................................... 4
Ohio Valley Heart Care ................................................................................................................................................................. 4
St. Mary's at Home ....................................................................................................................................................................... 4
St. Mary's Breast Center ............................................................................................................................................................... 4
St. Mary's Dietition ...................................................................................................................................................................... 4
St. Mary's Pulmonary Care/Lung Nodule Clinic ............................................................................................................................. 5
Pulmonary Care Referral Form ......................................................................................................................................16
St. Mary's Outpatient Rehab ........................................................................................................................................................ 5
Rehabilitation Order .....................................................................................................................................................17
Vestibular Rehab Order .................................................................................................................................................18
St. Mary's Respiratory Scheduling ................................................................................................................................................ 5
St. Mary's Rheumatology Care ..................................................................................................................................................... 5
Rheumatology Care Referral Form ................................................................................................................................19
St. Mary's Sleep Disorder Center .................................................................................................................................................. 5
Sleep Disorders Center Referral Form ............................................................................................................................20
Pediatric Sleep (see Center for Children) ........................................................................................................................ 3
St. Mary's Warrick Rehabilitation Center ..................................................................................................................................... 6
Warrick Rehab Order Form ...........................................................................................................................................21
St. Mary's Weight Management Center ....................................................................................................................................... 6
Weight Management Center Referral Form ..................................................................................................................22
St. Mary's Women's Physical Therapy .......................................................................................................................................... 6
Women’s Wellness Therapy Order Form .......................................................................................................................23
St. Vincent's OB/GYN Oncology .................................................................................................................................................... 6
St. Vincent's OB/GYN Oncology Referral Form .............................................................................................................24
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2

St. Mary’s Services
Office
Procedure
Center for Children (SPN)
St Mary’s Center for Children
(PHG/Jenison/Walsh)
Referral navigator assistance available for
every pediatric referral, even if services are
not available locally.
P: 812.485.7425
F: 812.485.7678
Imaging / Radiology Services
St. Mary’s Scheduling (SPN)
Will accept faxed referral form or EHR with the following
items included.
Include:
Your latest office note about the referral problem
Growth charts
Laboratory testing results
Imaging or radiology reports (last 6 months)
Endoscopy/pathology allergy reports (for GI referrals)
Operative/pathology reports
Legible insurance card
CFC will contact parent directly in 3‐5 business days.
*Referral form located on page 7
*Referral form required for Pediatric Sleep, located on page 8
Please call to schedule appointment, or fax order.
St. Mary’s Outpatient Lab‐Radiology
(PHG/Jenison/Walsh)
P: 812.485.6020 opt 1
F: 812.485.7567
Joslin Diabetes Center
P: 812.485.1814
F: 812.485.1804
Lab Services www.stmarys.org/lab‐resources
St. Mary’s Scheduling (SPN)
Will accept faxed referral form or EHR with the following
items included
Include:
Recent lab results for glucose
HGBA1C and lipid profile
Joslin will schedule appointment with patient directly
*Referral form on page 9
Please call to schedule appointment, or fax order.
St. Mary’s Outpatient Lab Radiology
(PHG/Jenison/Walsh)
P: 812.485.6020 opt 1
F: 812.485.7567
Maternal‐Fetal Medicine and Genetics
Center
P: 812.485.1894
F: 812.485.1870
Preferred method: Please call the MFM office to secure a date
and time of the appointment, then fax pertinent information.
Will accept faxed referral form or EHR with the following
items included
Include:
Prenatal records
Labs
All previous ultrasounds
*Referral form on page 10
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Medical Equipment (DME)
St. Mary’s DME (SPN, PHG, Jenison/Walsh)
P: 812.485.4600
F: 812.485.6513
Will accept faxed order with referral form or EHR order with
the following items included
Oxygen:
Qualifying/titration information
Device, Liter Flow, Hours of daily use
Medical Necessity forms required for matriarch brace and
rachis back brace
*Referral form and Medical Necessity forms located on pages
11‐14
Nephrology Associates
P: 812.479.3125
F: 812.491.6491
Will accept faxed referral with referral form or EHR with the
following items included.
Include:
Most recent office notes
Lab test results
*Referral form on page 15
OB/GYN
Partners in Women’s Health:
P: 812.485.7111
F: 812.485.7919
Henderson‐Partners in Women’s Health:
P: 270.831.6651
F: 270.831.1133
Preferred method: Please call the office to secure a date and
time of the appointment, then fax pertinent information. You
may also simply fax referral.
Fax previous office visit and include pertinent lab,
imaging, cytology, and pathology reports
Herman Reid, MD‐ Ft. Branch:
P: 812.753.5950
F: 812.753.5929
Ohio Valley Heart Care
P: 812.492.4278
F: 812.492.4213
Please call to schedule appointment, or fax referral.
St. Mary’s at Home
P: 812.485.7950
F: 812.485.7724
Please call for requests.
St Mary’s Breast Center
P: 812.485.4437
F: 812.485.6890
Please call to schedule appointment for screening. If patient is
experiencing clinical symptoms or provider indicates
diagnostic mammogram, please fax the order or send the
order with the patient.
St. Mary’s Dietitian
P: 812.485.6020
F: 812.485.7567
Please call to schedule appt or fax order.
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St. Mary’s Pulmonary Care / Lung Nodule
Clinic
P: 812.485.6030
F: 812.485.6032
Will accept faxed referral form or EHR with the following
items included.
Include:
Reason for referral
Chest X‐rays and/or CT
Hospital Records including Admission/Discharge
Summary
Most recent EKG and/or Echocardiogram
Recent labs/pathology reports
H&P and recent office notes for past 6 months
Current medication list
Allergy and Immunization list
Pulmonary Function Tests/Spirometry/Pulse Ox/6
minute walk
Cardiac Testing (Stress test, heart catheterization)
*Referral form on page 16
St. Mary’s Outpatient Rehab
(Physical Therapy, Occupational Therapy,
Speech Therapy)
P: 812.485.6020 opt 1
F: 812.485.5220
Will accept faxed order with referral form or EHR referral
order with the following items included
For site specific questions, call:
Washington Square: 812.485.5200
North Pointe: 812.485.6910
Main Campus:812.485.4521
Hydrotherapy
Modified Barium Swallow
*Referral form on page 17‐18
St. Mary’s Respiratory Scheduling
P: 812.485.6020 opt 1
F: 812.485.7567
Please call to schedule appointment, or fax order. Services
include:
Oxygen Qualification/Titration
Overnight Pulse Oximetry
Pulmonary Function Testing
St. Mary’s Rheumatology Care
P: 812.485.6030
F: 812.485.6032
St. Mary’s Sleep Disorders Center
P: 812.485.7680
F: 812.485.7576
Will accept faxed referral form or EHR with the following
items included.
Include:
Reason for referral
Recent labs (last 6 months)
Recent office visit notes
Current medication lists
Allergy lists
Diagnosis list
History and Physical
*Referral form on page 19
Referral form required
*Referral form on page 20
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St. Mary’s Warrick Rehabilitation Services
P: 812.897.7158
F: 812.897.7361
*Referral form on page 21
St. Mary’s Weight Management Center
*Surgical Program
P: 812.485.5858
F: 812.485.5815
St. Mary’s Women’s Physical Therapy
P: 812.485.5725
F: 812.485.5724
St. Vincent’s OB/GYN Oncology
P: 317.415.6740
F: 317.583.2496
Referrals are accepted in multiple ways:
*Provider calls for appointment
*Patient calls for appointment
* Will accept faxed referral or EHR with the following items
included.
Weight Management will schedule appointment with parent
directly.
*Referral form on page 22
Will accept faxed referral form or EHR with the following items
included.
Include
Diagnosis code and order
Patient Demographics
*Referral form on page 23
*Referral form on page 24
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Center for Children
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7

Pediatric Sleep
Pediatric Sleep Disorder Services
Referring physician’s printed name:
Office telephone
DX question Fax #
PLEASE FAX COMPLETED FORM with HISTORY & PHYSICAL or recent OFFICE NOTES and copy of
INSURANCE CARD. Patient will be scheduled for sleep study when information is received from your office and we
will fax appointment to your office.
Patient name:
DOB
/ /
age height weight
Address
Parent/ Guardian’s Name:
City State Zip phone Alt phone
√ ALL PATIENT PROBLEMS
INFANTS ONLY:
Behavior / academic
problems
Frequent awakenings
Other sleep
disturbance
Premature
Bedwetting Grinding teeth Restless legs Gestational age____wks
Choking/gasping Insomnia Sleep talking Craniofacial malformation
Chronic fatigue Morning headaches Sleep walking BPD
Difficulty initiating
sleep
Nightmares Snoring Neuromuscular Disease
Excessive daytime
sleepiness
Night sweats
Witnessed apnea
Family hx sleep
problems
Narcolepsy
Weight loss / gain
MEDICAL HISTORY
PAST PROCEDURES
(SEND REPORT)
Asthma Chronic sinusitis GERD Obesity EEG
Allergies Diabetes Hypertension
Previous T/A
Pulmonary Function Test
Anxiety /
Depression
Deviated septum Hx of Seizures
ADHD
Enlarged adenoids
Nasal
obstruction
Cardiac problems Enlarged tonsils Nasal polyps
Craniofacial
malformation
Enlarged tongue
Patient’s Special Needs
Small
pharyngeal
inlet
Sleep Environment
Oxygen? ___LPM Autism Crib
Toddler Bed
Breathing Tx’s Developmental delay
Bedrails Y or N
Aerosol Tx Yes/No Down’s syndrome Sleeps with parent
Tracheotomy Cerebral palsy Bedtime:_______
Special feedings?
N/G O/G G-tube
Wheelchair
ADDITIONAL INFORMATION:
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Weekday
Rise Time:________
date ________
Thyroid
disease
Allergies
Allergic
to:__________
Bronchoscope
Modified Barium Swallow
X-ray / MRI/ CT
Head/Neck
Recent blood tests
Current medications
NKDA
Latex allergy
Tape allergy
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Joslin Diabetes Center
3801 Bellemeade Ave. Suite 110
Evansville, IN 47714
812-485-1814
Referral/Order Form for Diabetes Training
Date: __________
*******Fax referral/order to 812-485-1804*******
W e will call patient to schedule appointment
Patient: _________________________________
Home Phone: _____________________________
Address: _________________________________
__________________________________________
__________________________________________
DOB: ___________ SSN: ________________
Diagnosis: 250.00 Type 2
250.02 Type 2, uncontrolled
790.21 Pre-diabetes/Impaired Fasting Glucose
790.22 Abnormal Glucose Tolerance
250.01 Type 1
250.03 Type 1, uncontrolled
Service Requested: (Please check all that apply)
Diabetes Training (DSME – Diabetes Self
Management Education encompasses 10 hours of
self management training and diet). Medicare allows 10
hours DSME in 12 month period, plus 2 hours follow up
annually.
Please specify # of hours education requesting if different
from the routine 10 hours _______
Medical Nutritional Therapy (MNT – Medical
Nutritional Therapy encompasses 3 hours in the first
calendar year, plus 2 hours of follow up annually.
Additional MNT hours available for change in
medical condition, treatment and / or diagnosis)
_____Initial MNT ____ annual Follow- up MNT
Diabetes self-management education ( DSME) and Medical Nutritional therapy
(MNT) are individual and complimentary services to improve diabetes care. For
Medicare beneficiaries, both services can be ordered in the same year. Research
indicates MNT and DSME improves outcomes
Please indicate any special needs requiring individual
Education:
Vision ___Hearing ___Language____
Cognitive Impairment___ Other _______________
648.83 GDM Gestational Diabetes
256.4 PCOS
648.03 Preexisting DM w/ pregnancy
(Type _______)
Other Special Service Requested (Please check)
Gestational Diabetes Training
Insulin Administration Instruction
Type _______________________________
Dosage _____________________________
Insulin Pump Training
Other __________________________
To assist us in assessing your patient, please check any of the
following that apply:
CHO counting
Annual Update
Pre-diabetes Class
Newly diagnosed/ Never had training
Other _______________________________
New to insulin or oral agent
Elevated A1C
PLEASE INCLUDE RECENT LAB RESULTS FOR GLUCOSE, HGBA1C, LIPID PROFILE
MD Signature: _______________________________________________
M D Name (print): __________________________
MD phone: __________________
MD fax: __________________
Referral for Diabetes Self Management Training: I certify that DSME services are needed under a comprehensive plan for this patients diabetes care for the
reason(s) listed above. I understand that patient reports will be sent at the end of the class series and after subsequent follow-up visits.
7219-20 01/2012
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Maternal Fetal Medicine and Genetics Center
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Home Oxygen
Phone (812) 485‐4600
Fax (812) 485‐6513
HOME OXYGEN ORDER
Patient: _______________________ DOB:_____________________
Phone:____________________________
Diagnosis: _________________________
Physician:________________________ Physician Phone: ____________________
Oxygen Orders:
_____ LPM continuous via nasal cannula
_____LPM ________________________________
_________________________________________ (please indicate if conserving device approved)
Required Oxygen Testing Information:
Date of Test:________________________________
Where Test was performed:______________________________
Tested at Rest without O2: ________ %
Test with Exercise without O2: ________%
Test with Exercise with O2: ________%
Additional Instructions:____________________________________________________
Physician Signature:___________________________
Date:______________________
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Nebulizer Form
Phone (812) 485‐4600
Fax (812) 485‐6513
NEBULIZER ORDER
Patient: _______________________ DOB:_____________________
Phone:____________________________
Diagnosis: _________________________
Physician:________________________ Physician Phone: ____________________
Equipment Order:
Nebulizer‐ Compressor (E0570)
Administration Set (A7005)
Mask (A7015)
(Medicare patients) Medication to be used with
Nebulizer_______________________________________________
(NOTE: St. Mary’s Medical Equipment does NOT supply or dispense the medications for nebulizers)
Length of Need: ______ months/ _______Lifetime
Additional Instructions:____________________________________________________
Physician Signature:___________________________
Date:______________________
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Letter of Medical Necessity‐Matriarch
_________________________
Date
_________________________
Patient's Name
DOB
___________________________
__________________________________________________________
Diagnosis
This letter documents the medical necessity for the PPI Matriarch Back Brace and can provide empirical evidence
for its efficacy with regard to this patient's condition. As prescribed, the Matriarch will assist in pain control by
dispersing the weight of the abdomen while helping to stabilize the patient in a neutral spinal position. The brace
comes standard with two adjustable cinching straps allowing the lower strap to anchor the brace to the body while
the upper strap maintains positioning of the abdomen without causing an increase in pressure over the fetus. This
positioning will form a “shelf” to help support the abdomen and spread the additional weight associated with the
pregnancy across the entire spine as well as through the rigid posterior panel, thus allowing a more neutral spinal
position and the subsequent elimination of back pain associated with a hyperlordotic posture. The brace itself is
made of a lightweight / breathable material designed to provide the appropriate amount of stabilization while still
allowing movement to promote activity and combat the muscle atrophy associated with movement restriction. It is
my professional opinion that without this brace, the patient is subject to further increases in pain and limitations of
activity that could further complicate the pregnancy and minimize patient function.
◊ PPI Matriarch: ________ L0631
Physician Signature
Date
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Letter of Medical Necessity‐Rachis
Letter of Medical Necessity, For PPI Rachis Back Bracing System
Detailed Written Physician Order, Prescription, Letter of Medical Necessity
_________________________
Date
_________________________
Patient's Name
DOB
___________________________
__________________________________________________________
Diagnosis
This letter documents the medical necessity for the Rachis Back Brace and can provide empirical
evidence for its efficacy with regard to this patient's condition. As prescribed, the Rachis has
effective compression coupled with the capability for hot/cold gel inserts to assist in pain control.
The brace also comes standard with 4 cinch straps to facilitate the appropriate amount of support
both circumferentially as well as accommodating varying amounts of lumbar curvature to
maximize both function and compliance. The brace itself is made of a lightweight / breathable
material and is designed to provide stabilization while still allowing movement to promote activity
and combat the muscle atrophy associated with movement restriction. It is my professional
opinion that without this brace, the patient is subject to further injury that could require prolonged
rehabilitation.
◊ 9” Rachis (L0627)
◊ 12” Rachis (L0631)
Physician's Name: ___________________________________________________
Address: ___________________________________________________________
City: ___________________________________ State: __________ Zip: ________
Phone: ___________________________ Fax: _____________________________
Physician's Signature NPI# UPIN# Date
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Nephrology
NEPHROLOGY
St. Mary’s Physician Network LLC
1312 Professional Blvd, Suite 200, Evansville, IN 47714
Phone 812-479-3125 Fax 812-491-6491
INCOMING REFERRAL
Please return with office notes and lab test results
PATIENT NAME: ______________________________ ________________________
ADDRESS:____________________________________________________________
__________________________________________________________
PHONE: (H) ____________ (W)__________________ (C ) __________________
DOB: ____________________ ____ SS#: ____________________________________
DIAGNOSIS ___________________________________________________________
INSURANCE INFO:
PRIMARY: ____________________________________
SECONDARY: _________________________________
IS PRECERT REQUIRED? YES
NO
REFERRING PHYSICIAN: _______________________________________________
SPECIALTY:________________________ N PI: _____________________________
PHONE: ___________________________
OFC CONTACT PERSON: _________________ F AX: ________________________
PHYSICIAN ADDRESS: _________________________________________________
PHYSICIAN PREFERENCE? ______________________________________________
APPOINTMENT DATE / TIME: ___________________________________________
APPOINTMENT WITH: __________________________________________________
SET UP BY: ____________ INFO SENT: _____________ DATE:_______________
ACCOUNT #_______________________
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Pulmonary Care
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Outpatient Rehab
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Vestibular Rehab
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Rheumatology
DATE______________________
St. Mary’s Rheumatology Care
Shilpa Gaitonde, MD
901 St. Mary’s Drive Suite 200
Evansville, Indiana 47714
Phone: (812) 485‐6030 Fax (812) 485‐6032
TO____________________________________________________
FROM________________________________________________
RE:___________________________________________________
We received your referral request for the above listed patient. Thank you for choosing St.
Mary’s Rheumatology to provide care to your patient.
Please send the information below so that we can promptly schedule your patient with Dr.
Gaitonde.
_________Recent Labs (the past 6 months)
_________Recent Office Visit Notes
_________Current Medication List
_________Allergy List
_________Diagnosis List
_________History and Physical
Thank you again for your attention to this request. We will notify you, as well as your patient,
of the appointment date and time.
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Sleep Disorders Center
**NOTE: PLEASE SEND H & P OR CONSULT NOTE WITH FORM**
***REMINDER: PLEASE SEND H & P OR CONSULT NOTE WITH REFERRAL FORM***
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Warrick Rehab Services
Warrick Hospital
REFERRAL FORM
1116 Millis Avenue Rehab Services
Boonville IN 47601-0629
Physical Therapy
Phone: 812 897-7158
Occupational Therapy
FAX: 812 897-7361
Speech Therapy
Patient’s Name:___________________________________________________
Diagnosis: _______________________________________________________
PT/OT
ST
□ Evaluation □Manual Tx □Speech/Lang Eval
□ Evaluate & Rx □ROM □Speech/Lang Eval & Rx
□ Gait Training □TENS □Dysphagia Eval
□ Back Program □Phonophoresis □Dysphagia Eval & Rx
□ Cryotherapy/Ice □Whirlpool □Oral Motor Rx
□Therapeutic Ex □Debridement □Other_________________
□ Hot Packs □HEP
□ Ultrasound □Vestibular
□ Eletrical Stim □W/C Evaluation THANK YOU FOR
□US/ES Combo □Developmental Assessment YOUR REFERRAL!
□ Iontophoresis □Other__________________
□Massage
_______________________
□ Splint
□ Cognitive RX
Frequency:____________________________________________________________
Precautions/Contraindications:____________________________________________
_____________________________________________________________________
PHYSICIAN SIGNATURE
Date:___________
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Weight Management Center
ST. MARY’S WEIGHT MANAGEMENT CENTER
950 S. Kenmore Dr.
Evansville, In. 47715
Phone (812) 485-5858
Fax (812) 485 5815
Patient Information:
PHYSICIAN REFERRAL
_____ For Medical Evaluation with Dr. Stephen Braun
For possible: ____ Roux-en-Y Gastric Bypass Surgery ____ Gastric Sleeve Surgery ____ Non-surgical MD Supervised Weight Loss
Please complete this form and fax to 812-485-5815. If you have any questions, please call 812-485-5858.
Name:____________________________ ______ Date of Birth:_____________ Gender:__________
Street Address:_______________________________ ______ Phone:_________________________
City:______________________________ State:_______________ Zip:______________________
Referring Physician Information:
Name: ___________________________________________________________ _________________
Office Street Address: ______________________________________________ _________________
City: _________________________ ______State: ________________Zip: _____________________
Office Phone: _____________________Office Fax: __________________ UPIN:_______________
Please check & list medication Diagnosis Code Description
278.00 Obesity
278.01 Severe Obesity, BMI 40 or higher
250.00 Type II Diabetes
250.02 Type II Diabetes, Uncontrolled
272.1 Hypertriglyceridemia only
272.4 Dyslipidemia
401.9 Hypertension
530.81 GERD
571.8 Fatty Liver (non-alcoholic)
327.23 Obstructive Sleep Apnea
790.21 Impaired Fasting Glucose (IFG)
715.99 Osteoarthritis
I feel this patient is a good candidate for consideration and evaluation for weight loss.
__________________________
Physician Signature
___________________
Date
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Women’s Wellness Therapy Services
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St. Vincent OB/GYN Oncology
8402 Harcourt Road, Suite 420
Indianapolis, IN 46260
Phone: 317‐415‐6740
Fax: 317‐583‐2496
http://www.stvincent.org/gynonc/
1. Patient Information:
Patient Name:
Date of Birth: ____________________
Patient Address:
City: State: Zip:
Patient Phone #: Patient Height:________ Weight________
Reason for Referral Request:
Insurance: YES or NO TYPE:
2. Referring Physician’s Information:
Name (PLEASE PRINT): ____________________________________________________________________
Ph #:_________________________ Fax: _________________________
Address__________________________________City____________________________State_____Zip______
NPI#: UPIN#: Medicaid #:
Physician’s Signature:
____________
3. Preferred MD:
Dr. Gregory Sutton
Dr. Michael Callahan
Dr. Hubert Fornalik
First Available
4. FAX THE FOLLOWING RECORDS TO: 317‐583‐2496
This Referral Sheet Completed as Cover Page
Current Lab Results
Clinical Notes Regarding Cancer Diagnosis or Referral Reason Pathology and Operative Reports
Patient’s Demographics and Insurance information Current List of Medications
Most recent PET Scan, CT Scan, MRI, Ultrasound, X‐Ray Reports
(Please mail CD’s of scans to our office or send with patient to bring to appt)
5. Please verify that we are in the patient’s insurance network and obtain any necessary authorization before her scheduled
appointment date.
6. Send Pathology Slides for Review to:
AMERIPATH
Attn: Denetrica / Ryan McCarthy, MD
2560 N. Shadeland Ave, Ste A
Indianapolis, IN 46219
*Please indicate which MD the patient is scheduled with when sending slides, so the proper one will receive the report.
Please double check that all information is filled out and complete and that all requested information that is appropriate has been included. You will
receive a fax back with appointment date and time once patient has been contacted and scheduled. We thank you for your kind referral.
Date fax sent:
Fax sent by:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐For GYN/ONC office use only.
Date Scheduled: Time Scheduled: With Dr:
Appointment Location: Indianapolis Fort Wayne Muncie Lafayette Evansville
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