Gunnison Valley Health Cancer Care Center
NPI: 1932109048 | Tax ID: 846008116 | Fax: 970-642-4774
Infusion Center Referral Form
We need the following information in order to best serve your patient and provide safe care.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Allergies
*
Weight
*
*
lbs
kg
Height
*
*
in
cm
Diagnosis and/or ICD-10
*
Insurance Type
*
Upload a copy of your current insurance card.
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Prior Authorization
Please complete all information
Prior Authorization #
Prior Auth MUST be initiated by referring provider's office. Prior Auth MUST list Gunnison Valley Hospital as Servicing Provider. NPI: 1932109048 | Tax ID: 846008116
No Prior Authorization Needed (Please add Reference # or specify Medicare NA)
Upload prior authorization documentation.
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Provider Information
Provider's Name
*
Signature
*
NPI
*
Date
*
-
Month
-
Day
Year
Date
Phone
*
Please enter a valid phone number.
Fax
*
Please enter a valid phone number.
Office Name and Address
*
Office Name
Address
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Person
*
Contact Email
example@example.com
Medication Information
Date of Last Treatment, if Continuation
-
Month
-
Day
Year
Date
Medication
*
Dose
*
Route
*
Frequency and Duration
*
Start Date of Infusion
-
Month
-
Day
Year
Date
End Date of Infusion
-
Month
-
Day
Year
Date
Pre-Medications
*
Lab Orders Associated with Treatment or Other Special Instructions
Please upload or fax copies of the patient information listed below. Fax number 970-642-4774.
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Demographics, Insurance Information, Current CBC & CMP, H&P Relevant to the Diagnosis, Current Medications
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