EXTERNAL ONLY MUST BE COMPLETE FOR GASTROENTEROLOGY, ENDOCRINOLOGY LIVER TRANSPLANT/FAILURE CLINIC, RHEUMATOLOGY Internal Medicine and Medical Specialists Phone: (352) 265 - 0139 Fax: (352) 265 - 7091
Consultation (Requesting consultation for a specialty option which will be used by the refereeing physician in care
management with or without co-management of care by the specialist) Transition of Care (Requesting referral for specialty evaluation and subsequent management of a problem by the specialist alone) PLEASE PRINT CLEARLY AND FILL OUT COMPLETELY Patient Name: ______________________ Authorized Contact Person (if different from Pt.): ______________________ Patient’s Social Security Number _________________ DOB: _______________ UF/Shands MR#: ______________________ Mailing Address: ______________________ City: ______________________ State: _____________ Zip: _____________ Preferred Phone Number: ______________________ Alt. Phone Number: ______________________ Insurance Company: ______________________Ins. Phone Number: ______________________ Policy/ID #: ______________________ Group #: ______________________ Employer: ______________________ ***If patient is a child, it is REQUIRED to include Guarantor / Guardian Information*** Subscriber / Guarantor Name: ______________________ Subscriber / Guarantor DOB: ______________________ Subscriber / Guarantor SS#:______________________Subscriber / Guarantor Phone # ______________________ Subscriber / Guarantor Address: ______________________ Relation to Patient: ______________________ Authorization Information (#, visits, expiration): ______________________ (If authorization is required, referring physician/clinic must complete prior to referral.)
Physician Requesting the Appointment Name: ______________________ Specialty: ______________________ NPI: ______________________ Mailing Address: ______________________ City: ______________________ State: _________ Zip: ____________ Phone Number: ______________________ Fax Number: ______________ Contact Person: ______________________ Person Completing Form: ________________________________________________________ Would you like to see the patient back in follow-up? Yes No Primary Care Physician
Same as above (if different, please complete below)
Name: ______________________ Phone Number: ______________________ Fax Number: ______________________ Mailing Address: ______________________ City: ______________________State: _________ Zip: ___________ Reason for appointment (Required): _______________________________________________________ Studies / Procedures requested: _______________________________________________________ Diagnosis / Problem / ICD-9: _______________________________________________________ Medications currently on: _______________________________________________________ All applicable clinical notes, recent lab work, radiological interpretations, copies of front and back of insurance cards, and any other pertinent information should accompany this request. Approved by Compliance 4/09
Attention UFP Staff: This form must be filled in the patient’s medical record.
