catholic-health-infusion-referral-form-1222v2

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INFUSION REFERRAL FORM 
 Please select location: 
 
Sisters of Charity Hospital 
 Depew Infusion Center 
 6199 Transit Road, Depew NY 14043 
 Ph: 716-891-1630/ Fax: 716-961-4490 
 Hours (by appointment only): 
 Monday-Wednesday: 7:30a-7p 
 Thursday & Friday: 7:30a-4p 
 NPI: 1790727543 
 TIN: 160743187 
 
Mount St. Mary’s Hospital 
 Infusion Services 
 5300 Military Road, Lewiston, NY 14092 
 Ph: 716-862-1066/ Fax: 716-862-1069 
 Hours (by appointment only): 
 Monday-Friday: 7:30a-4p 
 
 NPI: 1184252751 
 TIN: 161523353 
 
 
New Treatment Continuing Treatment If continuing, next treatment date:_____________ 
 
MEDICATION/TREATMENT REQUESTED: ______________________________________________ 
 
DIAGNOSIS CODE(S): __________________ CURRENT WEIGHT:_____________ HEIGHT:_______________ 
 
DATE OF REQUEST:_____________________ 
 
PATIENT NAME: _____________________________________ DATE OF BIRTH: __________________ 
 
GENDER:  MALE  FEMALE 
 
ALLERGIES:______________________________________________________________________________ 
 
PATIENT PHONE NUMBER: ____________________________________ 
 
REQUIRED DOCUMENTS (please submit with referral): 
 
☐ Patient Demographic Information 
 
☐ Insurance- copy of card(s), both sides 
 
☐H&P or Recent Clinic Note AND Relevant Lab Data 
 
☐Current medication list 
 
 
SPECIAL NEEDS/REQUESTS: ______________________________________________________________ 
 
 
REFERRING PHYSCIAN INFORMATION 
 
 
REFERRING PHYSICIAN/PROVIDER:_______________________________________________________ 
 
PHONE: ____________________________________ FAX: _______________________________________ 
 
OFFICE CONTRACT:_______________________________________________________________________