Patient Name
Date of Birth
Phone Number
Email
Address
City / State / Zip
Insurance
Member ID / Policy
Asthma J45.990
Shortness of Breath R06.02
Wheezing R06.2
COPD J44.9
Cough R05.3
Pulmonary Nodule R91.8
Pulmonary Fibrosis J64.10
Sarcoidosis D86
Morbid Obesity E65.2
RSV Pneumonia J12.82
Other Disorders of lung J98.4
OSA G47.33
Snoring R06.83
Other forms of dysnea R06.9
Narcolepsy J47.419
Please provide details for other evaluations...
Referring Provider Name
Fax Number
Contact Person
Comments Additional clinical notes...
Provider Signature / Stamp
Date
PLEASE don't forget to fax this form with medical records to: 1-866-531-4873
Call us to book an appointment at: 1-877-352-5864
Or book online at: Healow.com (Practice code: FGCHDD)
