Division Of Gastroenterology & Hepatology

Referring Physician Checklist

The following checklist describes the information we require when referring a patient. Please be prepared with this information when you contact the Gastroenterology Department.

Your contact information:

• Name

• Address

• Phone Number

• Fax Number

• Email

Information about your patient:

• Name

• Birthdate

• Address

• Phone Number

• Social Security Number

• Insurance Information

Your patient's complete Medical History and Records:

• Medical History

• Surgeries/Procedures

• Devices: type/settings

Description of your patient's current Medications:

• Type(s)

• Dosages

• Allergies

Diagnostic Test reports plus actual films or tracings:

• Chest x-ray, CT scans, ultrasounds: x-ray films plus report

• Endoscopy Reports

• Other