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Dr. William J. Fecht Jr.
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Search for:
Home
About Us
Dr. William J. Fecht Jr.
Office Staff
Hours & Locations
Hospital Affiliations
Patient Information
Forms & Instructions
COVID-19 Information
Policies
FAQ
Health Resources
Prescription Refill Request
Office Visit Request
Physician
Referrals
Urgent Referrals
Contact Dr. Fecht
Contact Us
Online Payments
Home
About Us
Dr. William J. Fecht Jr.
Office Staff
Hours & Locations
Hospital Affiliations
Patient Information
Forms & Instructions
COVID-19 Information
Policies
FAQ
Health Resources
Prescription Refill Request
Office Visit Request
Physician
Referrals
Urgent Referrals
Contact Dr. Fecht
Contact Us
Online Payments
Referrals
Referrals
DevMaster
2019-03-13T16:14:12-04:00
Please fill out the following information to refer a patient to Indiana Gastroenterology.
Patient Information
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
*
Mobile Phone
Email
Insurance Information
Please complete the information below or fax a copy of patient’s insurance card (front & back) to (317) 661-4657.
Subscriber Name
*
Employer Name
*
Insurance Provider
*
ID Number
*
Group/Account #
*
Precert Phone
*
Provider Svcs Phone
*
Claims Address
*
Appointment Information
Diagnosis
*
Services Requested
*
Office Consultation
Upper Endoscopy
Colonoscopy
ERCP
PEG Placement
Referrals for ERCP, PEG placement or colonoscopy (age over 75) at the discretion of the gastroenterologist may require an office consultation prior to their elective procedure.
Scheduling
*
First Available
Urgent
We will make every effort to schedule ‘urgent’ referrals within a week. Next day or same week scheduling may require physician-to-physician discussion.
Referring Physician Practice Information
Physician Name
*
Phone
*
Fax
*
Back-Line Phone
Email
Are you a new referring physician?
*
Yes
No
Complete this section once if your physician
has not
previously referred to our practice.
Practice Name
National Provider ID
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Additional Information
Do we need a referral from your office?
*
Yes
No
Does patient have any testing applicable to this referral?*
*
Yes
No
If "Yes", please fax pertinent records and test results to 317-819-5126.
Your Name
*
(Person submitting form)
Check the box below if you are a human
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