New Patient Referral

Patient information

The patient being referred to The Nephrology Group.

Demographics

Date

Last name

First name

Middle initial

Date of birth

Social Security number

Sex

MaleFemale

Address

City, state

ZIP code

Primary phone

Primary phone type

HomeCell

Secondary phone

Secondary phone type

HomeCell

Insurance

Primary insurance

ID number

Group number

Secondary insurance

ID number

Group number

Language assistance

Language assistance needed

NoYesDHHSC

Specify language

Referring provider and reason

Referring physician

Office contact person

Phone

Fax

Requested timing

ASAPNext available (2 to 4 weeks)

Diagnosis and reason for referral

Records to send

Please send the following so we may process your referral in a timely manner. One of our new patient referral coordinators will contact the patient within 24 to 48 hours after receiving the referral.

Anything else our coordinators should know

New Patient Referral Form