...........
...........Gainesville
Family Physicians, P.A.
...........Referral/Authorization Fax Request
To ensure a prompt response, please print clearly
and complete all requested
information. This form is used exclusively for fax referral/authorization
requests.
Faxes will be received and responded to Monday - Friday from 8:30 am to 4:30 pm.
Please fax all requests to Fax Number 352-331-2553
Patient's name:_____________________________________________
Date of birth: ___/___/___ Daytime phone:(123)_____-________ext____
Primary care physician:_______________________________________
Insurance company:___________ Insurance ID#:___________________
....................................................................(Not
group number)
Specialist's name and/or vendor #:_______________________________
Reason for visit and/or diagnosis code:____________________________
Appointment date (if known):___________________________________
Message:__________________________________________________
_________________________________________________________
_________________________________________________________
......Disclaimer
This facsimile is intended for the individual
or entity to which it is addressed and may
contain information that is privileged, confidential, or exempt from disclosure
under
applicable law. If the reader of this message is not the indented recipient,
or employee or
agent responsible for delivering the message to the intended recipient, you
are hereby
notified that any dissemination, distribution, or copying of this communication
is strictly
prohibited. If you have received this communication in error, please notify
us by calling
(325) 373-4359. Thanks you.