Is this referral urgent or emergent? If so, please call 812-477-6103.Referring Physician InformationContact Name* First Last Contact Phone*Referring Physician Name* First Last Referring Physician Phone*NPI (National Provider Identifier)* Referring Physician Fax*Requested Digestive Care Center - Newburgh First Available Provider Dr. Airel Dr. Bailey Dr. Boroda Dr. Gislason Dr. Khan Dr. Prasad Dr. Pugh Dr. Rao Dr. Rusche Requested Digestive Care Center - Jasper First Available Provider Dr. Hallett Dr. Potteiger Dr. Snyder Please include recent lab and/or radiology reports, office notes, and op reports as well as a copy of the patient's insurance cards(s) with this referral.Patient InformationPatient Name* First Middle Last Maiden Gender* M F DOB* MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Home Phone*Work PhoneCell PhoneEmail* Primary Insurance* Secondary Insurance Insurance ID Number* HiddenInsurance ID NumberInsurance Group Number* HiddenInsurance Group NumberGI Diagnosis for ReferralService Requested Colonoscopy Consultation ERCP Upper Endoscopy (EGD) Nutritional Services Lower Endoscopic Ultrasound (EUS) Upper Endoscopic Ultrasound (EUS) Other FileMax. file size: 512 MB.NotesPhoneThis field is for validation purposes and should be left unchanged.
