UGO New Patient Referral Workflow

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Primary Insurance Information

Policy Holder Name*

First Name

Middle Name (optional)

Last Name

Relationship To Insurance Policy Holder*

Policy Holder Date of Birth*

Primary Insurance Provider

Name of Insurance Company

Insurance Member ID

Group Number

Photo of Insurance Card - Front Side

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Photo of Insurance Card - Back Side

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Office Contact Information

Name of Referring Provider*

Name of person submitting referral

Office Phone Number

Your Email

Confirmation of appointment will be sent to this email address

Optional patient supporting records

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Has the patient been notified of their diagnosis and referral?

Yes No

Please be advised, we will not contact the patient to schedule an appointment until the provider has notified them of their diagnosis and intended referral.

Once you have notified the patient of their diagnosis and referral, please call our office at 865-305-5622.

Scheduling

Appointment Date and Time*

Provider *

Larry Kilgore, MD Kristopher Kimball, MD Jonathan Boone, MD

Location*

UT Main Campus Lenoir City Turkey Creek

Referring provider confirmed notifying the patient of referral*

Yes No

Name of office contact *

person who called to confirm that the patient was informed of referral

Date Contacted *

Date the referring provider office called to confirm patient ws notified of referral

University Gynecologic Oncology New Patient Referral Form

Primary Insurance Information

Office Contact Information

Scheduling