CONSULT-A-NURSE® / HEALTHCARE REFERRAL SERVICE SERVING HCA HOSPITALS IN FLORIDA, GEORGIA, TEXAS, VIRGINIA, KENTUCKY, INDIANA, NEW HAMPSHIRE, SOUTH CAROLINA, NEVADA, CALIFORNIA AND ALASKA. Please fax compeleted form to: ________________________________________________________ at ________________________________ PHYSICIAN PROFILE (please print) Hospital Name: _____________________________________________________________________________________________ _________________________________________________________________________________________________________ Physician Last Name ___________________ Date Physician First Name Middle Initial MD DO Other ____________________________ __________________________________________________________________ Physician NPI Number Name and Title of Person Completing Form Speciality __________________________________ (Y or N) Board Certified? ___ Board Eligible? ___ Accepting new pts.? ___ Sub Specialty _______________________________ (Y or N) Board Certified? ___ Board Eligible? ___ Accepting new pts.? ___ Sex  Male  Female Birthdate ____________________________________ Year started practicing? ___________ Year started on staff at this facility? ________________ What type of practice do you have (please check one)  Solo  Group Name of Practice __________________________________________________________________ What language(s) , other than English, do you speak? ________________________________________________________________________ What language(s), other than English, do your office personnel speak? _________________________________________________________ What age range of patients do you accept? (Please check all that apply)  Newborn: birth to 1 month  Infant: 2 months to 2 years  Child: 3-12 years  Adolescent: 13-17  Adult: 18 years and up  Geriatrics: 65 years and up Do you accept established patients without appointments?  Yes  No  No Do you make same day new patient appointments?  Yes If no, estimated waiting period of new patient appointments? ________________________________________________________________ Please indicate your educational/training background Name of Institution City/State/Country Year Graduated Undergraduate Degree Medical Education Internship Residency Fellowship BRH06166 Therapies and/or other diagnostic services i.e. lab, etc available on premises: __________________________________________________ ______________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Mailing Address: Street Address: ____________________________________________ Ste.#: _____ Bldg. Name: _______________________________________ City: ____________________________________________________________________________ State: ____ Zip: _______________________ Phone: __________________________________________________ Fax: ________________________________ Scheduling: _____________ Office Hours: _________________________________________________________________________________________________________ Lunch Hours: _________________________________________________________________________________________________________ Evening Hours: _________________________________________________ Weekend Hours: ________________________________________ Location: (if different from mailing address) Is this your main office?  Yes  No Street Address: ____________________________________________ Ste.#: _____ Bldg. Name: _______________________________________ City: ____________________________________________________________________________ State: ____ Zip: _______________________ Phone: __________________________________________________ Fax: ________________________________________________________ Office Hours: _________________________________________________________________________________________________________ Lunch Hours: _________________________________________________________________________________________________________ Evening Hours: _________________________________________________ Weekend Hours: ________________________________________ Additional Location: Is this your main office?  Yes  No Street Address: ____________________________________________ Ste.#: _____ Bldg. Name: _______________________________________ City: ____________________________________________________________________________ State: ____ Zip: _______________________ Phone: __________________________________________________ Fax: ________________________________________________________ Office Hours: _________________________________________________________________________________________________________ Lunch Hours: _________________________________________________________________________________________________________ Evening Hours: _________________________________________________ Weekend Hours: ________________________________________ INSURANCE/PAYMENT ACCEPTANCE INFORMATION: Please place an “X” in appropriate column. Yes No Payment plan available? Credit Card? Personal Check? Cash? PHYSICIAN PROFILE WORKSHEET Please use the following information to enhance your Physician profile. Insurance Plans Accepted (check all that apply) We accept all major insurance plans Other Plans Accepted Aetna First Health One Health Anthem Great West PacifiCare Auto Accident Insurance HealthNet PHP Beech Street Healthsource Preferred Health Network Blue Choice Horizon Private Health Care Systems Blue Cross Humana Prudential Blue Cross and Blue Shield Maxicare Secure Horizons Cigna Medicaid Workmen’s Compensation Coventry Medicare Workmen’s Compensation (out of state) Physician Philosophy: Provider’s viewpoint, values and approach to caring for and treating patients. You can also use a practice mission statement. Please provide any other information you would like the patient to be aware of about your or your practice. (maximum 1000 characters) Awards and Recognitions: 150 character maximum Date Award Conditions Treated: Procedures Performed: