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Here’s a checklist of the information you’ll need in order to refer a patient to a specialist at the Nasseff Specialty Center. Please have this information ready when calling to refer a patient.
Referring Physician Information
Name
Clinic/Practice Name
Address
Phone Number
Fax Number
E-mail
Patient Information
Name
Birth Date
Address
Phone Number
Social Security Number
Insurance Information
Patient's Medical History and Records
Medical History
Surgeries/Procedures
Devices: Type/Settings
Patient's Current Medications
Type(s)
Dosages
Allergies
Patient’s Diagnostic Test Reports
Actual Films
Tracings
Reports |
