Neurology Institute of Huntsville SELF REFERRAL

Neurology Institute of Huntsville
2006 Franklin St., Suite 202A, Huntsville, AL 35801

O: 256.489.0976 F: 256.489.0977
Diagnosis or suspected Diagnosis
Symptoms and Signs
Name
Address
Gender
Age
DOB
SS#
Phone (Cell phone)
Format: (000) 000-0000.
Alternative phone
Format: (000) 000-0000.
Primary Insurance
Contract#
Group
Secondary Insurance
Contract#
Group
Physician's Name
Practice/Office Name
Phone Number
Format: (000) 000-0000.
Fax Number
Thank you for your referral! We look forward to serving your neurology needs. We will contact you within 24-48 hours to be scheduled. Please ensure that you have checked with your insurance that

areferral from a doctor is not required to ensure a smooth process and no delays. If you do not hear

from us within 24-48 hours, please feel free to contact us at the number provided above.
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