VipMDCardiology & Primary Care

Fax to(661) 327-7593 Phone (661) 327-0807 · NPI 1124521018
4000 Physicians Blvd, Bldg E, Ste 101, Bakersfield, CA 93301

Cardiology Referral

Your patient seen within the week · urgent findings called to you the same day · written report faxed within five business days · your patient returns to you.

Referring provider

Provider name & credentials

Practice

Phone

Fax (reports go here)

NPI

Office contact for scheduling questions

Date of referral

Patient

Patient name (last, first)

Date of birth

Best phone

Preferred language

Insurance plan

Member ID

Authorization # (HMO / Kern Family Health, if obtained)

Reason for referral

Chest pain / pressure Shortness of breath Palpitations Syncope / near-syncope Abnormal EKG Murmur Hypertension Hyperlipidemia Leg swelling / edema Known CAD / heart failure Atrial fibrillation / arrhythmia Pre-operative evaluation

The question you want answered / clinical summary

Specific study requested, if already indicated (otherwise we'll evaluate and decide with you)

Urgency

Routine — within the week Soon — within a few days Urgent — I have called (661) 327-0807

Attached

Insurance card (front/back) Recent EKG Labs Prior echo / stress / imaging Medication list Recent progress note Authorization Other: ____________

Don't have it all? Send what you have — we'll request the rest from your office.

Referring provider signature

Date

VipMD Cardiology & Primary Care · 4000 Physicians Blvd, Bldg E, Ste 101, Bakersfield, CA 93301Fax (661) 327-7593 · Phone (661) 327-0807 · vipmd.com/for-providers

Confidential: this fax contains protected health information intended only for VipMD Cardiology. If received in error, notify us at (661) 327-0807 and destroy all copies.