Physician Referral Checklist Making a referral? This checklist will help you (or a staff member) get organized. Initial Contact Information Your Practice Information: Practice name Your name Address Phone number Fax number Email address Information About Your Patient: Name Name of parent or guardian (if the patient is a minor) Birthdate Address Phone number Social Security number Insurance information Has the patient previously been seen by a Highland Hospital or URMC physician? If so: Name(s) of physician(s) Date(s) If your patient belongs to an HMO or managed care plan, you may need to submit an approved referral form before the patient’s first visit including the number of visits authorized. For the Patient's First Visit: Medical History and Records Medical history Clinical summary Growth charts (for children) Past surgeries/procedures Devices: type/settings Current Medications: Type(s) Dosages Allergies Basic Diagnostic Tests: X-rays plus report CT scan images plus report Ultrasound images plus report MRI images plus report Pathology slides Blood work report Urine test report Specialized Diagnostic Tests (if any have been done): Echocardiogram: actual tape plus report Thallium stress test: actual x-ray film plus report Electrocardiogram: actual tracings if available Electrophysiology test: actual tracings and reports Cardiac catheterization: actual film plus report Electroencephalogram (EEG) report Nerve conduction study (NCS) report Electromyography (EMG) report Other Please ask your patient to bring in all medications, including over-the-counter drugs, any self-monitoring records, and any self-monitoring devices, such as a blood glucose meter. Before the appointment, your patient may receive instructions for the visit.