REFER A NEW PATIENT | Nephrology & Hypertension Associates

Referral Requirements
New referrals require last office notes and/or any renal scans or studies. Mississippi Kidney cannot schedule an appointment without office notes being provided.

Most recent lab results along with previous labs for baseline comparisons. If referring patient for proteinuria, must include 2-3 urinalysis showing protein present, or 24 hour urine result. Labs are non-negotiable. Mississippi Kidney cannot schedule an appointment without these.
Reason for Referral

Other
Requested Physician
Referring Provider Information
Referring Provider Name
Referring Provider NPI
Referring Clinic Name
Contact Name
Contact Phone Number
Contact Fax Number
Contact Email
Referring Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Information
Name

First NameMiddle NameLast Name
Social Security Number
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone
Cell Phone
Work Phone
Insurance Information

*If a referral is required for this patients insurance, it must be received before appointment can be made. It is the patient and/or referring provider responsibility to know the coverage.
Self Pay
Primary Insurance Carrier
Policy Number
Group Number
Policy Holder's Name
Policy Holder's Relationship
Policy Holder's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Medical Records Available

Other
Medical Records
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