New Patient Referral Form - East Tennessee Brain amp Spine: Fill out & sign online

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Click ‘Get Form’ to open the New Patient Referral Form in the editor.
Begin by circling the physician and location requested for the referral. Options include various doctors and locations such as Johnson City or Kingsport.
Fill in today’s date, sex, race, patient name, date of birth (DOB), social security number (SSN), address, and patient’s telephone number in the designated fields.
Enter the patient's insurance information. Remember to attach pertinent medical records and a copy of the patient’s insurance cards before submitting.
Complete the referring physician's details including their name, phone number, and NPI number.
Indicate if the patient has been seen by another neurosurgeon or pain management clinic by marking 'Y' or 'N' and providing doctor names if applicable.
Specify the reason for referral and priority level (Routine or Urgent) along with any additional details needed.

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