New Patient Referral Form

Neurology Institute of Huntsville Inc FAX Referral Form

Jitesh Kar, MD, MPH Board Certified Neurologist 2006 Franklin Street, Suite 202A, Huntsville, AL 35801 Phone: 256.489.0976 Fax: 256.489.0977 Website: www.NeurologyinstituteofHuntsville.com
Select Provider:*

Dr. Jitesh KarDr. Jeffrey NguyenLaura Cambron, NP1st Available
Referral for New Patient
Diagnosis or suspected diagnosis*
ICD 10 code*
Symptoms and signs*
Urgency:
Routine
ASAP (Need a call from physician)
Referral for procedure only (Please circle)

EMG/NCS (Electromyography, Nerve Conduction Study)
Patient Information:
Name*
Address*
Gender*
Age*
DOB*
SS#*
Phone (Cell phone)*
Alternate Phone
Primary Insurance*
Contract #
Group
Secondary Insurance
Authorization# if applicable
Referring Physician's Information:
Physician's Name*
NPI*
Practice/Office Name*
Phone*
Fax*
Thank you for your referral! We look forward to serving all of your patient's neurological needs. We will contact your patient as early as possible. Please ensure that required records are available to expedite the scheduling process. If you do not hear from our office, please feel free to contact us at the number provided above.

Download this form from our website:www.NeurologyinstituteofHuntsville.com
For office Use only

This Patient is scheduled onWe have called patient and left voicemail multiple times but have not received reply/response.Patient has refused to be scheduled.
Should be Empty:

Referral for New Patient