Referral to Gastroenterology & Hepatology Clinic 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Referring Physician Information section. Enter the physician’s name, date, office address, NPI number, city, state, fax number, zip code, and phone number. If there is a different primary care physician, include their details as well.
3. Next, move to the Patient Information section. Fill in the patient's full name, sex (select either Male or Female), address, city, state, home phone number, alternative phone number, insurance information (if available), zip code, and date of birth. Optionally include the spouse’s first name and indicate if an interpreter is needed.
4. In the Appointment Request section, specify the reason for referral and any provisional diagnosis. Indicate any special requests and ensure all pertinent medical records are ready for submission.
5. Select the specialty requested or specific physician from the provided options. Ensure you check all relevant boxes before proceeding.
6. Finally, fax this completed form along with all pertinent medical records to 414-955-6214.

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