1500 South 48th Street, Suite 506, Lincoln, Nebraska 68506, United States

Phone: (402) 489-1110 Fax: (402) 489-8492

Phone: (402) 489-1110 Fax: (402) 489-8492

  • Home
  • Our Providers
  • Patient Forms
  • Patient Referral
  • Contact Us
  • CID Patient Portal
  • More
    • Home
    • Our Providers
    • Patient Forms
    • Patient Referral
    • Contact Us
    • CID Patient Portal
  • Home
  • Our Providers
  • Patient Forms
  • Patient Referral
  • Contact Us
  • CID Patient Portal
Consultants In Infectious Disease, LLC

Patient referral

Need to refer a patient to our office:

Referral Process: 


  

Referral Request Form

*PLEASE FILL OUT COMPLETELY AND SEND ALL REQUESTED RECORDS TO ENSURE A QUICK REFERRAL PROCESS FOR THE PATIENT*

Please indicate if this is and URGENT referral

Patient Name: ______________________________________________ 


Date of Birth: ______________


Patient Phone   Number/Contact Information:_________________________


Reason For Referral:___________________________________________

_

Referring Provider:____________________________________________


Referring Provider fax/phone:_____________________________________


Please fax all requested information to 402-489-8492 or 402-489-1545

*Completed referral form

*Recent and pertinent office visit notes

*Labs relating to the referral diagnosis

*Diagnostic imaging reports relating to referral diagnosis

*Current medication list and allergies

*Demographic information with insurance card

Once all the above is received, the referral will be 

reviewed and we will call the patient to schedule 

Consultants In Infectious Disease, LLC

Copyright © 2022 Consultants In Infectious Disease, LLC - All Rights Reserved.

Powered by GoDaddy Website Builder