Port City Neurosurgery & Spine George A Alsina, MD 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the Referring Physician section. Enter the full name, NPI number, phone number, fax number, and direct mail address.
3. In the Reason for Referral field, provide a brief explanation of why the patient is being referred. Select when the patient needs an appointment from the options provided.
4. Next, complete the Patient section with their first name, middle/maiden name, last name, suffix, street address or P.O. Box, city, state, and zip code.
5. Fill in the patient's date of birth, age, sex, marital status, and social security number.
6. Provide contact information including home phone number, work phone number, cell phone number, and email address.
7. For Primary Insurance details, enter the insurance company name along with policy holder's name and date of birth. Include policy ID and group numbers as well as the date of injury.
8. If applicable, fill out Secondary Insurance information following the same format as Primary Insurance.
9. Ensure all required documents are prepared for submission: insurance card copy and relevant medical notes.

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