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About Us
Patient Information
Physician
Contact Us
Online Payments

Home
About Us
Patient Information
Physician
Contact Us
Online Payments

Referrals

ReferralsDevMaster2019-03-13T16:14:12-04:00

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 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 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

Carmel (primary) office

13421 Old Meridian St., Suite 201
Carmel, IN 46032
Phone: (317) 872-1161
Fax: (317) 661-4657

Noblesville (satellite) office

325 Westfield Road, Suite D
Noblesville, IN 46060
Phone: (317) 872-1161
Fax: (317) 661-4657

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© 2022 Indiana Gastroenterology, Inc. All Rights Reserved.

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Your physicians and staff at Indiana Gastroenterology are closely following the COVID-19 outbreak as are your primary care providers and referring physicians. Click here to read our full COVID-19 response information.

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