Fort Wayne Endoscopy Center
Referral Form

Please complete and press submit - required fields are marked with an asterisk (*)

If you prefer, you may also click here to download a PDF version of the form and fax it to: (260) 471-7444

           
  Referring Physician:* Date: MM/DD/YYYY
  Email:*    
           
  PROCEDURE REQUEST:      
    Screening Colonoscopy (asymptomatic)      
    Colonoscopy (no consult) Diagnosis:
    Upper Endoscopy (no consult) Diagnosis:
           
  IF HEALTH PLAN REQUIRES PCP REFERRAL, PLEASE INDICATE THE TYPE OF REFERRAL AUTHORIZATION
   
    Procedure Only (1 encounter)    
    Consult / Procedure (2 encounters)    
    Consult / Procedure / Follow-Up (3 encounters)    
           
  PATIENT INFORMATION:      
  Name:*  
  Address:  
  City: State: Zip:  
  Date of Birth: MM/DD/YYYY      
  Home Phone:* Work Phone:  
  Insurance: (Please FAX copy of insurance cards to 260-471-7444)
           
 
If patient has symptoms, please fax medical information to enable us to authorize the procedure
for insurance coverage.
           
  Is patient on blood thinners, i.e. Coumadin, Heparin, Plavix? (if yes, requires consultation)  
   
     
           
 

For questions, call 260-482-8001
or
Toll Free at 877-482-8001

We will contact your patient within 1-2 days of receiving this via email or fax.
 
           
 
Please press submit only ONCE to send your form to us.
           
 
CONFIDENTIALITY NOTICE
The documents accompanying this email or telecopy transmission contain confidential information. The information is intended only for use by the individuals or entity named above. If you are not the intended recipient, you are notified that any disclosure, copying, distribution, or taking of any action in reliance on the contents of this emailed or telecopied information is not permissible. If you have received this email or telecopy in error, please immediately notify us by telephone at 260-482-8001 to arrange for the return of the original documents. Thank you.