1350 Hickory St, Zone B Registration
Melbourne, Florida 32901

Phone: (321) 434 7313
Fax: 1(888) 338 1527

vip@bpadocs.com
www.vascularbrevard.com

 

Outpatient Referral Order

Please fill all blanks. Upload, fax or email supporting documentation (H&P, imaging report, labs)

Referring Office

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Patient Information

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Cell Phone Preferred

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Indication

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Procedure Requested

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Are specimens expected to be collected? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Requested Analysis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Select all that apply.

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Required Supporting Documents

Documents can be uploaded below, faxed to 1 (888) 338-1527 or emailed to vip@bpadocs.com

Lab work available? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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(completed within 90 days)

History & Physical available? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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(completed within 2 weeks of referral is preferable)

Previous Pertinent Imaging done? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Consulting Provider

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VIP-BPA internal use only:

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If "approved" or "clinic" are selected, this form serves as the order to schedule. 

 

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If the asnwer is "No", please write any "conditions" that need to be met prior to re-submitting for second triage (i.e obtain imaging, labs, order clarifications, etc).

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1350 Hickory St, Zone B Registration
Melbourne, Florida 32901

Phone: (321) 434 7313
Fax: 1(888) 338 1527

vip@bpadocs.com
www.vascularbrevard.com

 

Outpatient Referral Order

Please fill all blanks. Upload, fax or email supporting documentation (H&P, imaging report, labs)

Referring Office

Consulting Provider First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Consulting Provider Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Office Contact Person {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Office Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Fax {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Office Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Information

Patient First Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Patient Last Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date of Birth {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Home or Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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ID# {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Indication

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ICD-10 {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Notes {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Procedure Requested

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Is the procedure side specific? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Choose side {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Are specimens expected to be collected? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Requested Analysis {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Specific genetic mutation to be tested? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Required Supporting Documents

Lab work available? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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History & Physical available? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Previous Pertinent Imaging done? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date/Location where performed? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Upload Documents {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Consulting Provider

Consulting Provider Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date Consult Received {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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VIP-BPA internal use only:

Disposition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Is "Not approved" status final? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Notes (MUST INCLUDE DETAILED EXPLAINATION IF REQUEST NOT APPROVED) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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VIP-BPA Triaging Provider {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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VIP-BPA Provider Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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Date Triaged by VIP-BPA {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }
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