Provider Referral for GI Appointment For your convenience, please complete this online form. This is to help us better serve you and your patient. We will contact the patient and fax the appointment information to you with the date/ time within 24 business hours. For questions/ concerns, contact us at 706-548-0058. Thank you for your referral! Referring Physician: Contact Person: Phone Number: Fax: Patient Name: DOB: Patient Phone: Male/Female/Transgender: Symptom(s) or Reason for Appointment: Male Female Transgender from Male Transgender from Female Please be sure to fax any medical records pertaining to the reason for visit, such as: Last office note, recent lab results, GI Radiology, Endoscopy Reports, GI Pathology Reports, and patient’s insurance card to 706-548-0555. Primary Insurance: ID #: Group #: If patient’s insurance requires a referral authorization, please fax the authorization # to 706-548-0555. This referral will need to have an authorization number from the insurance company. We will call the patient to give them their appointment information. THANK YOU AGAIN FOR YOUR REFERRAL! Submitted online forms are confidential & encrypted.