Swedish Provider Referral Request
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Swedish Provider Referral Request
Date of request
*
Patient Information
First name
*
Middle name
*
Last name
*
Date of birth
*
Sex
*
Male
Female
Phone number
*
Patient home address
*
Insurance carrier
*
Proof of insurance
Please fax a photocopy of insurance information to 206-320-2655.
Referring Provider
First and last name
*
Specialty
*
NPI
*
Clinic name
*
Clinic address
*
Provider patient care coordinator
*
Phone number
*
Fax number
*
Email address
*
Referral
Referral type
*
Routine
Urgent (Appointment requested within five business days)
Emergent (Provider must call our Transfer Line for 24/7 admission by dialing 866-470-4233)
Reason for referral
*
Consultation (diagnosis / treatment / surgical opinion)
Transfer of care (Indicate condition or problem the specialist will manage)
Reason for request / diagnosis
*
Specialty or specific provider requested
*
Contact information
*
Swedish to contact patient to schedule appointment
Referring provider or his/her staff will be the point of contact for scheduling. Contact person name:
Patient Medical Records
Medical records are available
*
Yes
No
If medical records are available, please fax information to 206-320-2655.
Remarks