MEDICARE - Medical Referral Form
Referring MD, DO or medical Professional
*
First Name
Last Name
NPI#
*
Office Phone #
*
Please enter a valid phone number.
FAX #
*
Please enter FAX number.
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Phone #
*
Please enter patient's phone number.
Email
example@example.com
Primary Health Insurance
*
Please Select
MEDICARE Part B
Medicare Advantage plan
BCBS of GA
Anthem
UnitedHealth Care (UHC)
UHC - All Savers
UHC - Golden Rule
UMR
AETNA
Meritain Health
Nippon
CIGNA
MULTIPLAN
Other
Primary Subscriber ID#
*
Secondary Health Insurance
Secondary Subscriber ID#
DIAGNOSIS coverd by Medicare
*
N 18.1 - Chronic kidney disease, Stage 1
E10.64 - Type 1 Diabetes, with hypoglycemia
N 18.2 - Chronic kidney disease, Stage 2
E10.65 - Type 1 Diabetes, with hyperglycemia
N 18.3 - Chronic kidney disease, Stage 3
E11.2 - Type 2 Diabetes, with kidney compl.
N 18.4 - Chronic kidney disease, Stage 4
E11.5 - Type 2 Diabetes w/circulatory compl.
N 18.5 - Chronic kidney disease, Stage 5
E11.64 - Type 2 Diabetes w/hypoglycemia
Z 94.0 - Kidney transplant status
E11.65 - Type 2 Diabetes w/hyperglycemia
Other (add it below)
Other Diagnosis. Additional Information
Is patient cleared to exercise?
*
YES
NO
Please, upload LABORATORIES / medical notes or FAX 678-780-4313
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MD, DO, PAC - Signature
*
Name
*
First Name
Last Name
*Required
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