New Patient Referral Form

Neurology Institute of Huntsville Inc

2006 Franklin Street SE, Suite 202A, Huntsville, AL 35801
Dr. Jitesh Kar

Board Certified Neurologist
Reason for referral: *
ICD 10 code *
Symptoms and Signs *
Urgency:
Routine:
ASAP (Need a call from Physician)
Referral for procedure only

EEG (Electroencephalography) EMG/NCS ( Electromyography, Nerve Conduction Study)
Patient Information
Patient's Name: *
Address: *
Gender: *
Age *
Date of Birth *

Month Day Year
Date
SS#:
Phone Number *

Area Code Phone Number
Alternate Phone:

Area Code Phone Number
Primary Insurance: *
Contract #: *
Group: *
Secondary Insurance:
Authorization# if applicable:
Referring Physicians Information
Referring Physician's Name: *
Practice/office Name: *
NPI: *
Phone: *
Fax: *
Should be Empty:

Neurology Institute of Huntsville Inc