AFFZ11 Referral Form

DERMATOLOGY REFERRAL FORM
1. Office Location

Brookfield, WIWaukesha, WINew Berlin, WIGermantown, WIOak Creek, WI
2. PATIENT DETAILS - Contact Information
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Sex

MaleFemale
INSURANCE INFORMATION - *WE DO NOT ACCEPT MEDICAID HMO PLANS* WE DO ACCEPT SELF-PAY
Primary Insurance
Primary ID Number
To expedite your benefits confirmation, please attach a photo of the FRONT side of your PRIMARY insurance card. You can use your cell phone to take the picture.

Cancelof
To expedite your benefits confirmation, please attach a photo of the BACK side of your PRIMARY insurance card. You can use your cell phone to take the picture.

Cancelof
Do you have secondary insurance?

YesNo
Secondary Insurance
Secondary ID Number
To expedite your benefits confirmation, please attach a photo of the FRONT side of your SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
To expedite your benefits confirmation, please attach a photo of the BACK side of your SECONDARY insurance card. You can use your cell phone to take the picture.

Cancelof
3. REFERRING PHYSICIAN - Contact Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
4. SCHEDULING
When do they need to be scheduled?

UrgentRoutine
5. REASON FOR REFERRAL
Diagnosis

MohsLesionRashAcneOther
Body Location
Please fax this form and supporting documents including insurance cards to
(262) 754-4940
P: (262) 754-4488 | F: (262) 754-4940 | email: receptionist@affiliatedderm.com
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