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To refer a patient to the St.Vincent Center for Joint
Replacement, complete the following form.
* Indicates a field is required to Submit the form
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* Referring Physician Name :
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| Physician Group/Practice Name : |
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| * Practice Address : |
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| * Practice City: |
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| * Practice State: |
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| * Practice Zip Code : |
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| * Practice Telephone : |
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| * Practice Fax : |
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| Practice Email Address : |
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| * Patient Name : |
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| * Patient Address : |
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| * Patient City: |
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| * Patient State: |
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| * Patient Zip Code : |
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| * Patient Phone Telephone : |
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| Patient Email : |
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| How does the patient prefer
to be contacted? |
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| * Patient Date of Birth : |
(mm/dd/yyyy)
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| Patient Social Security Number : |
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| * Patient Diagnosis : |
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| * Affected joint : |
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| * Which Side : |
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| * Any patient special needs or requests
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| * Do you have a physician preference for
referral : |
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HIPAA Compliance
Physician and Center agrees that each will comply in all material respects with
all federal and state mandated regulations, rules or orders applicable to
privacy, security and electronic transactions, including without limitation,
regulations promulgated under Title II Subtitle F of the Health Insurance
Portability and Accountability Act (Public Law 104-191) ("HIPAA"). Furthermore,
the parties shall promptly amend their policies and practices to conform with
any new or revised legislation, rules and regulations to which Physician and
Center are subject now or in the future including, without limitation, the
Standards for Privacy of Individually Identifiable Health Information or
similar legislation (collectively, "Laws") in order to ensure that Physician
and Center are at all times in conformance with all Laws.
St.Vincent Center for Joint Replacement
8402 Harcourt Rd., Suite 128
Indianapolis, IN 46260
(317) 338-BONE (2663)
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