RAPID REFERRAL FORM

Date: _____/______/______

From:

Sender’s Fax #: Sender’s Phone #:

3. CALL patient scheduler at the numbers listed below:

Medical Oncology/Hematology/Gynecologic

(757) 213-5742 Radiation Oncology

Lake Wright: (757) 213-5770 Princess Anne: (757) 507-0425 Sentara CarePlex: (757) 827-2430 Sentara Obici: (757) 934-4482

1.

2.

EMAIL this form to the email addresses listed below and include all pertinent records:

VOASchedulers@USOncology.com

TO REFER OR SCHEDULE A NEW PATIENT:

Appointment Date: _____/______/______ Time: _____________________________ Patient Notified: Physician: __________________________________________________________________ Office Location: ___________________________________________________________

PATIENT PROFILE

Demographics sheet attached? ❏ yes ❏ no

Patient Name: _________________________________________________________________ DOB: ____/_____/_____ Sex: ❏ M ❏ F Last First MI

Patient Address: _______________________________________________________________________________________________________ Street City State Zip

Home Phone: ( ) _______________________________________ Cell Phone: ( ) ________________________________________

Social Security Number: _____________________________________ Place of Employment: ________________________________________

Race: ____________________________________________________ Language preferred: ________________________________________

INSURANCEPrimary Carrier:__________________________________________ Subscriber Name: ________________________________________

Policy #: ________________________________________________ Subscriber DOB: ____/_____/_____

Secondary Carrier:________________________________________ Subscriber Name: ________________________________________

Policy #: ________________________________________________ Subscriber DOB: ____/_____/_____

VIRGINIA ONCOLOGY ASSOCIATES - PHYSICIANSMedical Oncology and Hematology ❏ First Available ❏ Alberico ❏ Alencar ❏ Alexander ❏ Atienza ❏ Booth ❏ Bremer ❏ Chang ❏ Conkling ❏ Cross ❏ Damle ❏ Danso ❏ Fleming ❏ Goudar ❏ Harden ❏ Kessler ❏ Kok ❏ Kruger ❏ Lee ❏ Mattern ❏ McGaughey ❏ More ❏ Naga ❏ Paschold ❏ Powell ❏ Prillaman ❏ Radkar ❏ Saman ❏ Sile ❏ Tan ❏ Tian

Gynecologic ❏ First Available ❏ McCollum ❏ Rogers ❏ Squatrito

Radiation Oncology

Hereditary Risk Assessment Appointment

❏

❏

First Available ❏ Lake Wright (Jones/Miller) ❏ Princess Anne ❏ Sentara CarePlex (Kang/Miller) ❏ Sentara Obici (Archie)

REFERRING PHYSICIAN INFORMATIONReferring Physician: ________________________________________ Diagnosis: ________________________________________________

NPI: ____________________

(i.e. cancer type, heme, ICD-10 code, other)

❏ Routine ❏ Urgent

FOR INTERNAL USE ONLY

andFAX this form to the number listed below

include all pertinent records:

Medical Oncology/Hematology/Gynecologic

(757) 459-2740Radiation Oncology Lake Wright: (757) 213-5788 Princess Anne: (757) 507-0426 Sentara CarePlex: (757) 827-2432 Sentara Obici: (757) 934-4490

(Please note: Diagnosis is needed to obtain referral if required by insurance)

❏ Yes ❏ No ❏ Left Voicemail Other _____________

(If yes, please be sure all information below is included.)

Oncology Visit:DIAGNOSIS � Referring physician notes, initial consult, operation notes, procedure notes, any hospital records and a copy of the patient’s current medications � All radiology reports (chest x-rays, CT, MRI, PET, mammograms, bone scans, EKG, venous doppler, ultrasounds) � Most recent lab work (last 3 visits) � Pathology reports (needle biopsy, ER/PR, Her2Neu) � Tumor Markers, if feasible, to assist with staging and treatment plan

GYN Patients: Additional Information Needed for GYN Patients� PAP � Ultrasound � If patient is already diagnosed, � Pathology Reports � Radiology Reports � Labs

Hematology Visit:DIAGNOSIS � Referring physician notes, initial consult, operation notes, procedure notes, any hospital records and a copy of the patient’s current medications � All radiology reports (chest x-rays, CT, MRI, PET, mammograms, bone

scans, EKG, venous doppler, ultrasounds) � All lab work (CBC’s - previous 5 years, all others - 2 year history) � Pathology reports (needle biopsy, ER/PR, Her2Neu)

The US Oncology Network is supported by McKesson Specialty Health. © 2017 McKesson Specialty Health. All rights reserved.

Thank you for your assistance!Southside O�ces: (757) 446-8683 Peninsula O�ces: (757) 873-9400

AETNA US Healthcare -Traditional - EPO - PPO - HMO - POS - Exchange ProductsAnthem Blue Cross Blue Shield - Traditional - EPO - PPO - HMO - POS - Exchange Products - HealthKeepers Plus – Managed- Medicaid - Anthem HK Commonwealth Coordinated Care Plan - Medicare AdvantageBlue Cross Blue Shield North Carolina - Traditional - HMO - PPO - Exchange Products - Commonwealth Coordinated Care Plan

CIGNA - Traditional - POS - PPO - HMOCoventry (formerly First Health &Southern Health) - PPO - HMO - POSFortified Provider Network - PPOGalaxy Health Network - PPOHumana Medicare Advantage - PPO - HMO - PFFS - Commonwealth Coordinated Care PlanMAMSI - HMO - One Net PPO - MDIPA

Accepted Insurance*

In order for our physician to provide you and your patient with the best possible consultation, we will need the following

medical records PRIOR to the scheduled appointment:

Optima - PPO - HMO - POS - Sentara Family Care - Managed-Medicaid - Exchange Products - Medicare Advantage - SCQN NetworkTotal Health - Managed-MedicaidTricare - Standard PPO - Tricare for Life (Supp) - Prime HMOUnited Healthcare - Traditional - HMO - PPOVirginia Health Network (VHN) - PPO (TPA)Virginia Premier - Managed-Medicaid - CompleteCare Plan (Medicare-Medicaid Plan)Medicare - Virginia - North CarolinaMedicaid - Virginia - North Carolina

Rev: 2/2017