Physician Referral - Iowa Ortho

Your Information

Referring Clinic *

Name of Person Initiating Referral *

Phone *

Referring Physician *

Return Fax # *

Email Address

Requesting a consulting opinion for

Patient Name *

Patient DOB *

Patient Primary Phone Phone *

Patient Secondary Phone Phone *

Patient Email

Reason to be seen *

Preferred Iowa Ortho Provider *

Is the Patient their own Medical Decision Maker? *YesNo

Will an Interpreter be Needed for Patient? *YesNo

Patient Insurance Information

Billed to *Private InsuranceWork CompSelf Pay

Name of Insurance

Authorization Number

Address of Claims

Subscriber Name *

Subscriber Date of Birth *

Policy Number *

Group Number *

Supporting Documents

Clinic NotesClinic notes are required for a referral. Please upload clinic notes here, or fax to 515-248-8888. To upload multiple documents hold the Ctrl key while selecting documents.

Additional DocumentsIf the patient has had any of the following procedures for the diagnosis listed above, please check box. Each supporting document should be uploaded to this form or be faxed to 515-248-8888.

Second Opinions

Has the patient ever seen an Orthopaedic, PM&R or Pain Physician for this problem?YesNo

Physician Name

Dates

Has the patient ever had surgery on this body part?YesNo

Is there any hardware?

Is this work related?YesNo

Special or additional notes about this patient

A representative will contact the patient and your office with in 1 business day to schedule/convey an appointment time for the patient.