Referrals

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*

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