ADULT & PEDIATRIC MEDICINE – ALLEN & FRISCO

PHONE: (972) 359-0000      FAX: (972) 359-1000      E-MAIL: MAIL@CLINIC2000.COM

PRIMARY PHYSICIAN REFERRAL

Plan Type:

HMO    PPO   EPO   POS

 

Member's Last Name: First Name: MI:

Member Number: --

Blue Cross Blue Shield Phone Number: 1800-413-0869

Referral From: (PRIMARY PHYSICIAN ONLY)

Physician(s):

Syed Shah        Nasneen Talukder

Azra Jagani       Hasina Hussain

Address:

City: State: ZIP:

Phone Number:

Referral To:

Name:

Address:

City:  State: ZIP:

Phone Number:   Doctor ID Number:

Offices Requested (This section must be completed for the referral to be valid)

Office Visit/Consult Only (Excludes Diagnostic Services)

Office Visit/Diagnostics

Office Visit/Diagnostics & Treatment

(Non-Office Surgery Must Be Pre-Certified)

Second Opinion Only, Send Results To PCP

Other:

Visits:

(Expires 60 Days From The Date of Referral Regardless of # of Visits Indicated)

 

1 OV         2 OV'S      3 OV'S      4 OV'S

5 OV'S      6 OV'S      7 OV'S      8 OV'S

Other:

 

Clinical Information

 

Diagnostics:

 

Referrance #:

PRIMARY CARE PHYSICIAN REFERRAL MUST BE ACCOMPANIED BY ALL PERTINENT LAB, X-RAY, AND DIAGNOSTICS 

SIGNATURE: __________________________________ DATE: _______________________

 

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