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Referral Form

The referring physician should provide this medical and demographic information. After all information entered is reviewed just click the “Send Referral” button, and this form will automatically be sent to B.T.W. Providers.
Referral Date:	(mm/dd/yyyy)
Reason:
Patient Information
First Name
Middle Name
Last Name
Street Address:
City:
State:
Zip code:
SSN:
DOB:	(mm/dd/yyyy)
Home Phone:
Work Phone:
Cell:
Email Address:
Attorney?	Yes    No
Attorney Name:
Attorney Phone:
Date of Accident:	(mm/dd/yyyy)
Claim #:
Body Part Involved:
Diagnosis:
Medical Records?	Yes   No
Diagnostic Film?	Yes   No
Surgery?	Yes   No
Surgery Date:	(mm/dd/yyyy)
Surgery Procedure:
Referring Physician:
Office Name:
Phone:
Fax:
Date of Rx:	(mm/dd/yyyy)
Frequency/Duration:
Insurance Information
Primary:
Phone:
Carrier/TPA:
Secondary:
Phone:
Carrier/TPA:
Prescription:	Patient HasWill Fax Please Obtain
Needs Transportation?	Yes   No
Needs Translation?	Yes   No
Comments:
Note: Your email address will be used to send a confirmation of this request. If there are any questions or concerns before submitting this Referral Form, please contact us at (786) 507-1600 or Referrals@btwproviders.org. Thank you.

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