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  • Physician Request Form

    Thank you for the referral of your patient!
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  • If an authorization is required, please include that with the request form

  • 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.

  • PLEASE SEND PERTINENT RECORDS, SUCH AS:

    • Labs
    • Ultrasound reports
    • Office notes
  • Physician or Advanced Practicing Nurse:

  • 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: