Institute for Heart and Vascular Health |
P 775-982-2400 |
1500 E 2 nd St ., Ste . 400 ( P1 ) |
F 775-982-8020 |
Reno , NV 89502 |
Cardiology Referral
Please complete form , print , sign , then fax to our engagement center : 775-982-8020 . Please include any pertinent clinical documentation including notes , imaging reports , lab results , etc .
Referring Clinic Name : __________________________________________________________ Address : ______________________________________________________________________ Phone : ___________________________ Fax : _________________________
Date : _______________
Patient Name : ___________________ ____________________ ( First Name ) ( Last Name )
DOB : ____________
Diagnosis : ______________________________________________________________________
Authorization #: ________________________________________ ( Indicate ‘ none ’ if not required ) Expiration Date : _________________
Insurance : _____________________________________________________________________ ( Please submit patient face sheet with demographics and copies of insurance cards )
Ordering Physician : __________________ ___________________ ________________ ( First Name ) ( Last Name ) ( Title )
Physician Signature : _______________________________________________
Please check service desired : � General Cardiology APP � General Cardiology MD � Structural Heart Program
� Heart Failure Program � Cardiac Electrophysiology � Women ’ s Heart Center
Comments :
Fax to : 775-982-8020