1. Fax or Call Your Referral to Siskin Hospital Outpatient Department.
To fax: Fax referral form (or comparable paperwork) to Siskin Hospital, Attn: Outpatient Referrals at (423) 634-4578.
To call: Call the Outpatient Referral Desk at (423) 634-1400.
2. Required Information for Referrals
a. Patient Name
b. Home Phone
c. Any Alternate Phone Numbers
d. Diagnosis(es)
e. Signed and Dated Physician's Order Listing Services Requested (Note:
Preprinted order pads are available upon request)
f. Referring Physician's Phone and Fax Number
g. Contact Name or Scheduling Appointments, if other than the patient
3. Additional Information Needed To Schedule
Appointments
a. Date of Birth
b. Social Security Number
c. Current Address
d. Insurance Policy Numbers (please indicate primary, secondary, tertiary,
etc)
e. Date of Onset Illness or Accident
f. Emergency Contact Name and Phone Number
g. Martial Status
h. Sex
i. Dates/Times Patient is Available for Therapy
4. Appointment Confirmation
An appointment confirmation notice will be faxed to your office with the date and time of the patient(s) appointments. You will be notified if we are unable to reach the patient or the patient declines the service.
