Polycystic Kidney Disease Referral for Consultation

2000 6th Avenue South - TKC 4th Floor Birmingham, Alabama 35233

Tel: 205-934-9509

Fax: 205-934-1879

Is your referral urgent?

UrgentNon-Urgent

Patient First Name

Patient Last Name

Patient DOB

Address

Street Address

City

State

ZIP/Postal Code

Patient Email

Primary Phone Number

Alternate Phone Number

Emergency Contact Phone Number

Insurance Information

Insurance Company

Insurance Address

Street Address

City

State

ZIP/Postal Code

Phone Number

Insured First Name

Insured Last Name

Policy Number

Group Number

Pre-Certification/Referral Number

Pharmacy Benefits Information (if available)

*Insurances not accepted: United Healthcare Alonex, BCBS High Performance Network

Office Name

Office Phone Number

Office Fax Number

Diagnosis prompting consultation

Will your patient require special assistance during their visit? (please specify, i.e. interpreter, wheelchair, financial, social work, etc.)

Requested Priority

Requested MD

Location: The Kirklin Clinic of UAB Hospital

Pertinent medical records such as labs, last clinic note, operative notes, imaging studies (CT/US/PET), genetic testing results, and copy of insurance card must be included with this referral form. Please have the patient bring copies of imaging studies on CD to the appointment. Thank you.

Michal Mrug, M.D.

Takamitsu Saigusa, M.D.

Jared Cook, M.D.

Efren A. Chavez Morales, M.D.

Lisa Farris, CRNP