FAX REFERRAL REQUEST Kent Yamaguchi, M.D., FACS

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FAX REFERRAL REQUEST Kent Yamaguchi, M.D., FACS
FAX REFERRAL REQUEST
Kent Yamaguchi, M.D., FACS - Hand & Plastic Surgeon
2365 E. Fir Avenue · Fresno, CA 93720
Phone: 559.978.0020 · Fax: 559.797.9005
www.UniversityMDs.com
Referrals can be made by faxing this form or calling the office.
Date:
Number of Pages:
Referring Physician:
Phone:
Referring Contact Person:
Fax:
PCP (if different from referring):
Phone:
Patient Name:
DOB:
Patient Home Phone:
Patient Cell:
Reason for Referral:
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


Skin Cancer (please send pathology report if available)
Skin Lesion (please specify): ____________________________
Hand Complaints
Others (please specify): ________________________________
Please send us a copy of the following items to expedite the process of this request:
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


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Copy of prior authorization form from insurance company
Copy of patient information sheet
Copy of patient insurance card
Copy of last chart notes
Pertinent Labs, X-rays, Pathology reports etc.
Medication List
Thank you for this referral. If you should have any questions, please call us at 559.797.9000.
Thank you very much for referring your patient to our office.
* * * * * * * * * * * * * * * * * * * * * * * * INTERNAL USE ONLY * * * * * * * * * * * * * * * * * * * * * * * *
Appointment Date:
Time:
Medical Record #:
Updated: May 2016

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