Physician Request Form

Physician Request Form

Thank you for the referral of your patient!
ASAP REFERRAL – Patient will be scheduled with first available provider in 1 week.
Patient Name
Date of Birth

Month Day Year
Date
Address
City
State
Zip Code
Home Phone Number
Work Phone Number
Cell Phone Number
Insurance (PLEASE SEND A COPY OF CARDS)
If an authorization is required, please include that with the request form
Referring Physician Fist Name
Referring Physician Last Name
Referring Physician Practice
Contact Person
Address
City
State
Zip Code
Private Line Number
Fax Number
Meaningful Use Stage 2 - Core Measure 15

The EP who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of such transitions and referrals either (a) electronically transmitted using CEHRT to a recipient or (b) where the recipient receives the summary of care record via exchange facilitated by an organization that is a NwHIN Exchange participant or in a manner that is consistent with the governance mechanism ONC establishes for the NwHIN.
Our office would like to send you a summary of care through direct messaging, please provide the listed referring physician above direct message address:
Referring Diagnosis (PLEASE BE SPECIFIC)
PLEASE SEND PERTINENT RECORDS, SUCH AS:
- Labs
- Ultrasound reports
- Office notes
Location

East Lansing – Main Campus Mason – South Campus
Physician, Advanced Practicing Nurse, or Midwife Preference:
Obstetrics/Gynecology

Erica Leigh Behring, M.D. Sara Cramton, MD Stephanie Fleming, MD Sharon Kelley, MD Kevin London, MD Renee Stevens, DO Elizabeth Thomas, MD LaKeeya Tucker, DO Abby Brown, CNM, NP Nicole Jamieson, RN, NP Laura Kelly, RN, NP Julie Malloch, RN, NP Stacey Tanay, RN, NP Jennifer Thomas, RN, NP No Preference
Obstetrics/Gynecology Midwives

Keri Kordie, RN, CNM Desirae Michalisko, RN, CNM Sarah Schultz, RN, CNM Jodi Williamsen, RN, CNM No Preference
Please Note: Your patient will receive a packet of information that must be filled out and brought to the appointment. Thank you for the referral. Please call our office if you have any questions.
Should be Empty: