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

Your Referral Guide to St. Mary’s ServicesAt 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 alsoobtain the most current information at the following link: www.stmarys.org/referralFor Further Information, Please Contact:Amy Susott, RRT, MPSADirector, Strategic DevelopmentPhone: 812.485.6983 Cell: 812.455.0804alsusott@stmarys.orgJulie MorrowSenior Business DevelopmentCoordinator, Strategic DevelopmentPhone: 812.485.7095Julie.Morrow@stmarys.orgShannon EarhartSenior Coordinator, Strategic DevelopmentPhone: 812.485.4972Shannon.Earhart@stmarys.orgREV. 07.19.2013

Table of Contents:Center For Children ...................................................................................................................................................................... 3Center for Children Referral Form .................................................................................................................................. 7Pediatric Sleep Referral Form ......................................................................................................................................... 8Imaging/Radiology Services ......................................................................................................................................................... 3Joslin Diabetes Center .................................................................................................................................................................. 3Joslin Diabetes Center Referral Form .............................................................................................................................. 9Lab Services ................................................................................................................................................................................. 3Maternal‐Fetal Medicine and Genetics Center ............................................................................................................................. 3Maternal Fetal Medicine and Genetics Center Referral Form ........................................................................................10Medical Equipment (DME) ........................................................................................................................................................... 4Home Oxygen Order Form ............................................................................................................................................11Nebulizer Order Form ....................................................................................................................................................12Letter of Medical Necessity‐Matriarch ..........................................................................................................................13Letter of Medical Necessity‐Rachis ................................................................................................................................14Nephrology Associates ................................................................................................................................................................. 4Nephrology Referral Form .............................................................................................................................................15OB/GYN ....................................................................................................................................................................................... 4Ohio Valley Heart Care ................................................................................................................................................................. 4St. Mary's at Home ....................................................................................................................................................................... 4St. Mary's Breast Center ............................................................................................................................................................... 4St. Mary's Dietition ...................................................................................................................................................................... 4St. Mary's Pulmonary Care/Lung Nodule Clinic ............................................................................................................................. 5Pulmonary Care Referral Form ......................................................................................................................................16St. Mary's Outpatient Rehab ........................................................................................................................................................ 5Rehabilitation Order .....................................................................................................................................................17Vestibular Rehab Order .................................................................................................................................................18St. Mary's Respiratory Scheduling ................................................................................................................................................ 5St. Mary's Rheumatology Care ..................................................................................................................................................... 5Rheumatology Care Referral Form ................................................................................................................................19St. Mary's Sleep Disorder Center .................................................................................................................................................. 5Sleep Disorders Center Referral Form ............................................................................................................................20Pediatric Sleep (see Center for Children) ........................................................................................................................ 3St. Mary's Warrick Rehabilitation Center ..................................................................................................................................... 6Warrick Rehab Order Form ...........................................................................................................................................21St. Mary's Weight Management Center ....................................................................................................................................... 6Weight Management Center Referral Form ..................................................................................................................22St. Mary's Women's Physical Therapy .......................................................................................................................................... 6Women’s Wellness Therapy Order Form .......................................................................................................................23St. Vincent's OB/GYN Oncology .................................................................................................................................................... 6St. Vincent's OB/GYN Oncology Referral Form .............................................................................................................24REV. 07.19.20132

St. Mary’s ServicesOfficeProcedureCenter for Children (SPN)St Mary’s Center for Children(PHG/Jenison/Walsh)Referral navigator assistance available forevery pediatric referral, even if services arenot available locally.P: 812.485.7425F: 812.485.7678Imaging / Radiology ServicesSt. Mary’s Scheduling (SPN)Will accept faxed referral form or EHR with the followingitems 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 cardCFC will contact parent directly in 3‐5 business days.*Referral form located on page 7*Referral form required for Pediatric Sleep, located on page 8Please call to schedule appointment, or fax order.St. Mary’s Outpatient Lab‐Radiology(PHG/Jenison/Walsh)P: 812.485.6020 opt 1F: 812.485.7567Joslin Diabetes CenterP: 812.485.1814F: 812.485.1804Lab Services www.stmarys.org/lab‐resourcesSt. Mary’s Scheduling (SPN)Will accept faxed referral form or EHR with the followingitems includedInclude: Recent lab results for glucose HGBA1C and lipid profileJoslin will schedule appointment with patient directly*Referral form on page 9Please call to schedule appointment, or fax order.St. Mary’s Outpatient Lab Radiology(PHG/Jenison/Walsh)P: 812.485.6020 opt 1F: 812.485.7567Maternal‐Fetal Medicine and GeneticsCenterP: 812.485.1894F: 812.485.1870Preferred method: Please call the MFM office to secure a dateand time of the appointment, then fax pertinent information.Will accept faxed referral form or EHR with the followingitems includedInclude: Prenatal records Labs All previous ultrasounds*Referral form on page 10REV. 07.19.20133

Medical Equipment (DME)St. Mary’s DME (SPN, PHG, Jenison/Walsh)P: 812.485.4600F: 812.485.6513Will accept faxed order with referral form or EHR order withthe following items includedOxygen: Qualifying/titration information Device, Liter Flow, Hours of daily useMedical Necessity forms required for matriarch brace andrachis back brace*Referral form and Medical Necessity forms located on pages11‐14Nephrology AssociatesP: 812.479.3125F: 812.491.6491Will accept faxed referral with referral form or EHR with thefollowing items included.Include: Most recent office notes Lab test results*Referral form on page 15OB/GYNPartners in Women’s Health:P: 812.485.7111F: 812.485.7919Henderson‐Partners in Women’s Health:P: 270.831.6651F: 270.831.1133Preferred method: Please call the office to secure a date andtime of the appointment, then fax pertinent information. Youmay also simply fax referral. Fax previous office visit and include pertinent lab,imaging, cytology, and pathology reportsHerman Reid, MD‐ Ft. Branch:P: 812.753.5950F: 812.753.5929Ohio Valley Heart CareP: 812.492.4278F: 812.492.4213Please call to schedule appointment, or fax referral.St. Mary’s at HomeP: 812.485.7950F: 812.485.7724Please call for requests.St Mary’s Breast CenterP: 812.485.4437F: 812.485.6890Please call to schedule appointment for screening. If patient isexperiencing clinical symptoms or provider indicatesdiagnostic mammogram, please fax the order or send theorder with the patient.St. Mary’s DietitianP: 812.485.6020F: 812.485.7567Please call to schedule appt or fax order.REV. 07.19.20134

St. Mary’s Pulmonary Care / Lung NoduleClinicP: 812.485.6030F: 812.485.6032Will accept faxed referral form or EHR with the followingitems included.Include: Reason for referral Chest X‐rays and/or CT Hospital Records including Admission/DischargeSummary 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/6minute walk Cardiac Testing (Stress test, heart catheterization)*Referral form on page 16St. Mary’s Outpatient Rehab(Physical Therapy, Occupational Therapy,Speech Therapy)P: 812.485.6020 opt 1F: 812.485.5220Will accept faxed order with referral form or EHR referralorder with the following items includedFor site specific questions, call:Washington Square: 812.485.5200North Pointe: 812.485.6910Main Campus:812.485.4521 Hydrotherapy Modified Barium Swallow*Referral form on page 17‐18St. Mary’s Respiratory SchedulingP: 812.485.6020 opt 1F: 812.485.7567Please call to schedule appointment, or fax order. Servicesinclude: Oxygen Qualification/Titration Overnight Pulse Oximetry Pulmonary Function TestingSt. Mary’s Rheumatology CareP: 812.485.6030F: 812.485.6032St. Mary’s Sleep Disorders CenterP: 812.485.7680F: 812.485.7576Will accept faxed referral form or EHR with the followingitems 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 19Referral form required*Referral form on page 20REV. 07.19.20135

St. Mary’s Warrick Rehabilitation ServicesP: 812.897.7158F: 812.897.7361*Referral form on page 21St. Mary’s Weight Management Center*Surgical ProgramP: 812.485.5858F: 812.485.5815St. Mary’s Women’s Physical TherapyP: 812.485.5725F: 812.485.5724St. Vincent’s OB/GYN OncologyP: 317.415.6740F: 317.583.2496Referrals are accepted in multiple ways:*Provider calls for appointment*Patient calls for appointment* Will accept faxed referral or EHR with the following itemsincluded.Weight Management will schedule appointment with parentdirectly.*Referral form on page 22Will accept faxed referral form or EHR with the following itemsincluded.IncludeDiagnosis code and order Patient Demographics*Referral form on page 23*Referral form on page 24REV. 07.19.20136

Center for ChildrenREV. 07.19.20137

Pediatric SleepPediatric Sleep Disorder ServicesReferring physician’s printed name:Office telephoneDX question Fax #PLEASE FAX COMPLETED FORM with HISTORY & PHYSICAL or recent OFFICE NOTES and copy ofINSURANCE CARD. Patient will be scheduled for sleep study when information is received from your office and wewill fax appointment to your office.Patient name:DOB/ /age height weightAddressParent/ Guardian’s Name:City State Zip phone Alt phone√ ALL PATIENT PROBLEMSINFANTS ONLY:Behavior / academicproblems Frequent awakenings Other sleepdisturbance Premature Bedwetting Grinding teeth Restless legs Gestational age____wks Choking/gasping Insomnia Sleep talking Craniofacial malformation Chronic fatigue Morning headaches Sleep walking BPD Difficulty initiatingsleep Nightmares Snoring Neuromuscular Disease Excessive daytimesleepiness Night sweats Witnessed apnea Family hx sleepproblems Narcolepsy Weight loss / gainMEDICAL HISTORYPAST 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 Nasalobstruction Cardiac problems Enlarged tonsils Nasal polyps Craniofacialmalformation Enlarged tonguePatient’s Special Needs SmallpharyngealinletSleep EnvironmentOxygen? ___LPM Autism Crib Toddler Bed Breathing Tx’s Developmental delayBedrails 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 WheelchairADDITIONAL INFORMATION:REV. 07.19.2013WeekdayRise Time:________date ________ ThyroiddiseaseAllergiesAllergicto:__________BronchoscopeModified Barium SwallowX-ray / MRI/ CTHead/NeckRecent blood testsCurrent medications NKDA Latex allergy Tape allergy8

Joslin Diabetes Center3801 Bellemeade Ave. Suite 110Evansville, IN 47714812-485-1814Referral/Order Form for Diabetes TrainingDate: __________*******Fax referral/order to 812-485-1804*******W e will call patient to schedule appointmentPatient: _________________________________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, uncontrolledService Requested: (Please check all that apply) Diabetes Training (DSME – Diabetes SelfManagement Education encompasses 10 hours ofself management training and diet). Medicare allows 10hours DSME in 12 month period, plus 2 hours follow upannually.Please specify # of hours education requesting if differentfrom the routine 10 hours _______Medical Nutritional Therapy (MNT – MedicalNutritional Therapy encompasses 3 hours in the firstcalendar year, plus 2 hours of follow up annually.Additional MNT hours available for change inmedical condition, treatment and / or diagnosis)_____Initial MNT ____ annual Follow- up MNTDiabetes self-management education ( DSME) and Medical Nutritional therapy(MNT) are individual and complimentary services to improve diabetes care. ForMedicare beneficiaries, both services can be ordered in the same year. Researchindicates MNT and DSME improves outcomesPlease indicate any special needs requiring individualEducation: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 InstructionType _______________________________Dosage _____________________________ Insulin Pump Training Other __________________________To assist us in assessing your patient, please check any of thefollowing that apply:CHO countingAnnual UpdatePre-diabetes Class Newly diagnosed/ Never had training Other _______________________________ New to insulin or oral agent Elevated A1CPLEASE INCLUDE RECENT LAB RESULTS FOR GLUCOSE, HGBA1C, LIPID PROFILEMD 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 thereason(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 01/2012REV. 07.19.20139

Maternal Fetal Medicine and Genetics CenterREV. 07.19.201310

Home OxygenPhone (812) 485‐4600Fax (812) 485‐6513HOME OXYGEN ORDERPatient: _______________________ 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:______________________REV. 07.19.201311

Nebulizer FormPhone (812) 485‐4600Fax (812) 485‐6513NEBULIZER ORDERPatient: _______________________ DOB:_____________________Phone:____________________________Diagnosis: _________________________Physician:________________________ Physician Phone: ____________________Equipment Order:Nebulizer‐ Compressor (E0570)Administration Set (A7005)Mask (A7015)(Medicare patients) Medication to be used withNebulizer_______________________________________________(NOTE: St. Mary’s Medical Equipment does NOT supply or dispense the medications for nebulizers)Length of Need: ______ months/ _______LifetimeAdditional Instructions:____________________________________________________Physician Signature:___________________________Date:______________________REV. 07.19.201312

Letter of Medical Necessity‐Matriarch_________________________Date_________________________Patient's NameDOB_____________________________________________________________________________________DiagnosisThis letter documents the medical necessity for the PPI Matriarch Back Brace and can provide empirical evidencefor its efficacy with regard to this patient's condition. As prescribed, the Matriarch will assist in pain control bydispersing the weight of the abdomen while helping to stabilize the patient in a neutral spinal position. The bracecomes standard with two adjustable cinching straps allowing the lower strap to anchor the brace to the body whilethe upper strap maintains positioning of the abdomen without causing an increase in pressure over the fetus. Thispositioning will form a “shelf” to help support the abdomen and spread the additional weight associated with thepregnancy across the entire spine as well as through the rigid posterior panel, thus allowing a more neutral spinalposition and the subsequent elimination of back pain associated with a hyperlordotic posture. The brace itself ismade of a lightweight / breathable material designed to provide the appropriate amount of stabilization while stillallowing movement to promote activity and combat the muscle atrophy associated with movement restriction. It ismy professional opinion that without this brace, the patient is subject to further increases in pain and limitations ofactivity that could further complicate the pregnancy and minimize patient function.◊ PPI Matriarch: ________ L0631Physician SignatureDateREV. 07.19.201313

Letter of Medical Necessity‐RachisLetter of Medical Necessity, For PPI Rachis Back Bracing SystemDetailed Written Physician Order, Prescription, Letter of Medical Necessity_________________________Date_________________________Patient's NameDOB_____________________________________________________________________________________DiagnosisThis letter documents the medical necessity for the Rachis Back Brace and can provide empiricalevidence for its efficacy with regard to this patient's condition. As prescribed, the Rachis haseffective 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 supportboth circumferentially as well as accommodating varying amounts of lumbar curvature tomaximize both function and compliance. The brace itself is made of a lightweight / breathablematerial and is designed to provide stabilization while still allowing movement to promote activityand combat the muscle atrophy associated with movement restriction. It is my professionalopinion that without this brace, the patient is subject to further injury that could require prolongedrehabilitation.◊ 9” Rachis (L0627)◊ 12” Rachis (L0631)Physician's Name: ___________________________________________________Address: ___________________________________________________________City: ___________________________________ State: __________ Zip: ________Phone: ___________________________ Fax: _____________________________Physician's Signature NPI# UPIN# DateREV. 07.19.201314

NephrologyNEPHROLOGYSt. Mary’s Physician Network LLC1312 Professional Blvd, Suite 200, Evansville, IN 47714Phone 812-479-3125 Fax 812-491-6491INCOMING REFERRALPlease return with office notes and lab test resultsPATIENT NAME: ______________________________ ________________________ADDRESS:______________________________________________________________________________________________________________________PHONE: (H) ____________ (W)__________________ (C ) __________________DOB: ____________________ ____ SS#: ____________________________________DIAGNOSIS ___________________________________________________________INSURANCE INFO:PRIMARY: ____________________________________SECONDARY: _________________________________IS PRECERT REQUIRED? YESNOREFERRING 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 #_______________________REV. 07.19.201315

Referral FormSt. Mary’s Pulmonary CarePhone: 812-485-6030Fax: 812-485-6032To provide the best patient experience, these documents are essential to our specialists:• Chest X-rays &/or CT; films on disc if not done at St. Mary’s• Most recent EKG & ECHO• Labs• H & P and Office Notes/Progress Notes last 6 months• Legible Copy of Insurance Card(s)• Current Medication List• Spirometry/Pulmonary Function TracingsDate of Referral:______________________________Patient Name:_______________________________________________________________________DOB: ________________________________________ SS#:___________________________________Complete & Current Address:____________________________________________________________________________________________________________________________________________Home#:_____________________________________ Cell#:_________________________________Insurance:__________________________________________________________________________Diagnosis/ Reason for Referral:________________________________________________________Referring Physician:__________________________________________________________________Referring Office Contact:_____________________________________________________________Referring Office Phone & Fax #’s:______________________________________________________**Patient’s Primary Care Provider:______________________________________________________You will be contacted by St. Mary’s Pulmonary Care staff with the patient’s appointmentdate and time. Thank you for allowing us to participate in the care of your patient.7321-20 Rev. 07/2012

Outpatient RehabREV. 07.19.201317

Vestibular RehabREV. 07.19.201318

Referral FormSt. Mary’s Rheumatology CarePhone: 812-485-6030Fax: 812-485-6032To provide the best patient experience, these documents are essential to our specialists:• Chest X-rays &/or CT; films on disc if not done at St. Mary’s• Labs results last 6 months (including most recent RA, ANA with titer, ESR, CRP,other immunology tests, CBC with differential & platelet, Liver panel)• H & P and Office Notes/Progress Notes last 6 months• Legible Copy of Insurance Card(s)• Current Medication ListDate of Referral:______________________________Patient Name:_______________________________________________________________________DOB: ________________________________________ SS#:___________________________________Complete & Current Address:____________________________________________________________________________________________________________________________________________Home#:_____________________________________ Cell#:_________________________________Insurance:__________________________________________________________________________Diagnosis/ Reason for Referral:________________________________________________________Referring Physician:__________________________________________________________________Referring Office Contact:_____________________________________________________________Referring Office Phone & Fax #’s:______________________________________________________**Patient’s Primary Care Provider:______________________________________________________You will be contacted by St. Mary’s Rheumatology Care staff with the patient’s appointmentdate and time. Thank you for allowing us to participate in the care of your patient.7983-08 Rev. 07/2012

Sleep Disorders Center**NOTE: PLEASE SEND H & P OR CONSULT NOTE WITH FORM*****REMINDER: PLEASE SEND H & P OR CONSULT NOTE WITH REFERRAL FORM***REV. 07.19.201320

Warrick Rehab ServicesWarrick HospitalREFERRAL FORM1116 Millis Avenue Rehab ServicesBoonville IN 47601-0629Physical TherapyPhone: 812 897-7158Occupational TherapyFAX: 812 897-7361Speech TherapyPatient’s Name:___________________________________________________Diagnosis: _______________________________________________________PT/OTST□ 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 RXFrequency:____________________________________________________________Precautions/Contraindications:_________________________________________________________________________________________________________________PHYSICIAN SIGNATUREDate:___________REV. 07.19.201321

Weight Management CenterST. MARY’S WEIGHT MANAGEMENT CENTER950 S. Kenmore Dr.Evansville, In. 47715Phone (812) 485-5858Fax (812) 485 5815Patient Information:PHYSICIAN REFERRAL_____ For Medical Evaluation with Dr. Stephen BraunFor possible: ____ Roux-en-Y Gastric Bypass Surgery ____ Gastric Sleeve Surgery ____ Non-surgical MD Supervised Weight LossPlease 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 Description278.00 Obesity278.01 Severe Obesity, BMI 40 or higher250.00 Type II Diabetes250.02 Type II Diabetes, Uncontrolled272.1 Hypertriglyceridemia only272.4 Dyslipidemia401.9 Hypertension530.81 GERD571.8 Fatty Liver (non-alcoholic)327.23 Obstructive Sleep Apnea790.21 Impaired Fasting Glucose (IFG)715.99 OsteoarthritisI feel this patient is a good candidate for consideration and evaluation for weight loss.__________________________Physician Signature___________________DateREV. 07.19.201322

Women’s Wellness Therapy ServicesREV. 07.19.201323

St. Vincent OB/GYN Oncology8402 Harcourt Road, Suite 420Indianapolis, IN 46260Phone: 317‐415‐6740Fax: 317‐583‐2496http://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 SuttonDr. Michael CallahanDr. Hubert FornalikFirst Available4. 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 scheduledappointment date.6. Send Pathology Slides for Review to:AMERIPATHAttn: Denetrica / Ryan McCarthy, MD2560 N. Shadeland Ave, Ste AIndianapolis, 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 willreceive 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 EvansvilleREV. 07.19.201324