patient information referring physician park rowe avenue baton rouge, la 70810 phone: 225.769.2200...

Download PATIENT INFORMATION REFERRING PHYSICIAN   Park Rowe Avenue Baton Rouge, LA 70810 Phone: 225.769.2200 T  PHYSICIAN FAX REFERRAL REQUEST/ORDER FAX THIS REFERRAL TO APPOINTMENT SCHEDULING AT 225.768.2186

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  • 10101 Park Rowe Avenue

    Baton Rouge, LA 70810

    Phone: 225.769.2200

    TheNeuroMedicalCenter.com

    PHYSICIAN FAX REFERRAL REQUEST/ORDER

    FAX THIS REFERRAL TO APPOINTMENT SCHEDULING AT 225.768.2186. We will call your patient and schedule an appointment. Thank you for your referral. If you have any other questions, call Scheduling at 225.768.2050.

    PATIENT INFORMATION (Please print)

    Patients Name________________________________________________________________________________ D.O.B._______/_______/____________ Street Address___________________________________________________ City____________________________ State______ Zip_________________ Home Phone (______) _______________________ Cell Phone (______) _______________________ Work Phone (_______) _______________________ Diagnosis_______________________________________________________________________ Diagnosis Code_________________________________ Insurance Name_________________________________ Member #___________________________________ Group #____________________________

    *****Please attach a copy of the insurance card if possible.*****

    REFERRING PHYSICIAN INFORMATION

    MD Name (print)_____________________________________________________________________ Date______________________________________ Signature of Referring Physician__________________________________________________ Nurse/Contact_____________________________________ Phone (______)______________________ FAX (______) __________________________ Physicians Secure E-mail ______________________________

    SERVICES REQUESTED NEUROSURGERY - 3

    RD FLOOR NEUROSURGERY (continued) PHYSICAL MEDICINE & IMAGING SERVICES1

    ST FLOOR

    Charles R. Bowie, M.D. (Adults) Richard A. Stanger, M.D. (Adults) REHABILITATION/ (Please send previous records.)

    Baton Rouge Baton Rouge PAIN MEDICINE 3RD

    FLOOR MRI* MRA* X-Ray*

    Eunice Covington Martin A. Langston, M.D.

    Luke A. Corsten, M.D. (Adults) Walker John E. Nyboer, M.D.

    DIAGNOSTIC SERVICES-4th

    FLOOR

    Baton Rouge Paul J. Waguespack, M.D (Adults) Scott D. Nyboer, M.D EEG

    Gregory Fautheree, M.D. (Adults) Baton Rouge Samir K. Patel, M.D. EEG 24 Hour Ambulatory

    Baton Rouge First Available Baton Rouge Carotid Ultrasound

    Eunice Gonzales Transcranial Doppler

    St. Francisville NEUROLOGY 4TH

    FLOOR Walker EMG*

    Allen S. Joseph, M.D. (Children) Gerald J. Calegan, II, M.D. Jyoti S. Pham, M.D. Nerve Conduction*

    Baton Rouge Charles E. Eberly, M.D. First Available BAER

    Horace L. Mitchell, M.D. (Adults) April A. Erwin, M.D. VER

    Baton Rouge Dariusz W. Gawronski, M.D. OUTPATIENT THERAPY 4th

    FLOOR SSEP/PT

    Eric K. Oberlander, M.D. (Adults) B. Glenn Kidder, Jr., M.D. Physical Therapy SSEP/MN

    Baton Rouge Jon D. Olson, M.D. Occupational Therapy *Please provide specifics in

    Covington Darian E. Reddick, M.D. Hand Therapy Comments section

    Hammond Mehdi Soltani, M.D. Dry Needling DURABLE MEDICAL

    Kelly J. Scrantz, M.D. (Adults) Rebecca E. Whiddon, M.D. Kinesio Taping EQUIPMENT

    Baton Rouge First Available Back Brace

    Gonzales TENS unit

    Scott W. Soleau, M.D. (Adults) NEUROPSYCHOLOGY-4TH

    FLOOR Readi-Steadi Anti-Tremor

    Baton Rouge John F. Bolter, Ph.D., M.P. Hand Orthotic

    St. Francisville Jessica L. Brown, Ph.D., M.P.

    Darla M.R. Burnett, Ph.D., M.P. Insurance Authorization #

    Brooke B. Cole, Ph.D., M.P. __________________________

    Paul M. Dammers, Ph.D., M.P. Expiration Date:

    First Available

    Comments________________________________________________________________________________________________________________ MRI_________________________________________________________MRA________________________________________________________ X-Ray_______________________________________________________EMG/NCV____________________________________________________

    REVISED 04/2017

    FOR THE NEUROMEDICAL CENTER CLINIC TO COMPLETE Your patient is scheduled as follows:

    Doctor/Test__________________________________ Date__________________ Time____________ Location___________________________

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