ATHENS GASTROENTEROLOGY ASSOCIATION

To
Location
Patient name
DOB
Address
City
State
ZIP
Home #
Work #
Cell #
Gender
SS #
Reason for Referral
Priority Level(Circle)
Insurance Information
Primary Insurance	ID # Group #
Secondary Insurance	ID # Group #
(For BCBS insurance only) Open Access

If this patient has Medicaid Georgia Better Healthcare, South East Community Care, BCBS HMO/POS (not including open access), Kaiser, or Tricare Prime (standard not included) please fax the insurance referral to our office. Please fax latest office notes, lab results, x-ray reports and any information pertinent to this office visit.

Referring Physician
Primary Care Physician
Contact Person
Office Phone
Office Fax