REFERRAL REQUEST Urgency RoutineUrgentEmergent   THANK YOU for referring your patient to Houston Endocrinology Center. This form is to be completed by the outside referring provider or designee. For your convenience we included a list of most common endocrine icd-9 codes for you to select from. Patient Name: ___________________________ DOB: __________________________________ Social Security Number: ___________________ Phone Number: __________________________ Address: _______________________________________________________________________ Insurance Company: _____________________________________________________________ Referring Provider Name: _________________________________________________________ Provider Phone #: ________________________ Fax #: __________________________________ Provider Address: ________________________________________________________________ Email Address: __________________________________________________________________ Patient’s Primary Care Provider: ____________________________________________________ Indicate Reason for Referral: Thyroid Disorders: _____790.99 Abnormal TFT’s _____240.00 Goiter _____241.00 Thyroid Nodule _____242.90 Hyperthyroidism _____244.90 Hypothyroidism _____193.00 Thyroid Carcinoma _____783.10 Weight Gain _____783.21 Weight Loss Reproductive Function: _____629.9 Female _____628.9 Male _____704.1 Hirsutism _____256.4 PCOS Carbohydrate & Lipid Metabolism: _____250.00 Diabetes Mellitus _____V45.85 Insulin Pump Status _____272.9 Lipid Disorders _____259.9 Hypoglycemia Bone & Mineral Metabolism: _____252.0 Disorders of Parathyroid Gland _____275.4 Disorders of Calcium Metabolism _____733.0 Osteoporosis _____268.0 Vitamin D deficiency Adrenal Disorders: _____255.9 Unspecified Disorders of Adrenal Glands Pituitary Disorders: _____253.9 Pituitary Disorders Other ICD: _____________ Diagnosis:_______________________________________________ Reason for Request: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Referring Provider’s Signature: _____________________________________________________ Date of Referral: _________________________________________________________________