PHYSICIAN REFERRAL FORM
Texas Institute for Neurological Disorders
Main Office : 321 North Highland Avenue, Suite 200, Sherman TX - 75052
For Referral: Phone: 903-891-4287 Fax: 903-328-3222 Email: referrals@texomaneurology.com
Patient Preference:
Please select Office:
Please select service:
[ ] Denison
[ ] Durant
[ ] Mckinney
[ ] Plano
[ ] Richardson
[ ] Sherman
[ ] Consult
[ ] EMG/NCV
[ ] EEG
[ ] Pain Procedure Evaluation
Reason for Referral and Diagnosis: __________________________________________________________________
Patient Information:
Patient Name:
Address:
_______________________________________________________________________
______________________________________________________________
City:
DOB:
____________________________
____________________________________________
State: ___________ Zip Code: __________________ Telephone # (s) ______________________________________________________
Email Id : ___________________________________________________________________________________________________________
Please include the following as much as you can with this form to setup the appointment quickly.
[ ] Copy of insurance card
[ ] Prior authorization # (if applicable) ______________________________
[ ] Medical Records (include the office note referencing referral to a neurologist)
[ ] Diagnostic test results (include MRIs, lab work, etc. applicable to the referral)
Referring Physician Information:
Referring Physician: _______________________________________________ NPI #: _________________________________
Name of Practice/Facility: _________________________________ Group Practice NPI #:________________________
Referring Physician Phone #: ______________________________________ Fax: ___________________________________
Referral Sent by (contact name): __________________________________ Ext: ___________________________________
Contact email: ________________________________________________________
(Internal use to fax back to referring physician)
Account #:
Location :
______________ Appointment Date: _____________________ Time: ______________
w/ Dr: ___________________________________