:: Online Patient Referral ::

Fast Track Scheduling
Email: speerwing@procaresystems.com
additional med records can be emailed to address above
or faxed to 616 285-1377

Please submit this form using the button below, and email or fax appropriate patient medical information, to our central scheduling location at TCPC. We will call your patient to schedule an initial consult in the first available appointment and will notify you of the appointment details. The yellow fields are required information, if you will be faxing

Date:

Referring Physician:

Referring Physician Phone:

Fax:

Referring Physician UPIN

State License #

Medicaid #

Primary Care Physician:

Primary Physician UPIN

State License #

Medicaid #

Patient Name:

Patient Phone Number:

Patient Address:

City:

State:

Zip Code:

DOB:

Social Security #:

Employer of Insured Party:

Contact Person & Number:

Is this:	Work Related - Claim #:
Worker’s Comp Carrier Name/Number:
Is this:	Auto Related - Claim #:
Auto Carrier Name/Number:
Claim Adjuster Name/Number:
If Authorization number needed (HMO or Managed Care) Auth #

Primary Insurance:	Insured ID# :		Group # :
Subscriber’s Name:	Spouse	Dep	Self
Secondary Insurance:	Insured ID# :		Group # :
Subscriber’s Name:	Spouse	Dep	Self

Reason For Referral/Specialist Request:

TCPC OFFICE USE ONLY: APPOINTMENT SCHEDULED

PACKET SENT:

EMPLOYEE INITIALS:

TIME:

DATE:

PHYSICIAN:

LOCATION: