River Valley Musculoskeletal Center River Valley Musculoskeletal Center : Fort Smith, AR
RVMC : The Best People Giving The Best Care
   
  For Appointments or
Additional Information,
Call 479-709-6700 		 
  Click Here to Request Your Appointment   REQUEST
Your Appointment 		 
  Click Here to Cancel Your Appointment   CANCEL
Your Appointment 		 
 
  Physician's Referral
 

NOTICE: This form is ONLY to be submitted by certified physicians and/or their staff. All submitted information will be verified for credibility upon receipt. If you prefer not to submit a referral electronically, CLICK HERE to download a PDF printable version of the form. You may fill out and fax the form to us at 479.709.7030.

 
 
 
  STEP 1 : ENTER DOCTOR'S OFFICE INFORMATION  
     
 
Doctor Name:  
 
 
Dr. Office Phone #:  
 
 
Dr. Office Fax #:  
 
 
Office Contact Name:  
 
 
Office Contact E-Mail:  
 
 
Referral For (Doctor Name or Specialty):  
 
 
Who Should Be Contacted Regarding This Request?   Office Contact Patient
 
 
Preferred Time To Be Called:  
 
 
 
  STEP 2 : ENTER PATIENT INFORMATION  
     
 
Patient Name:  
 
 
Patient Phone # :  
 
 
Patient DOB:     Patient SSN:  
 
 
Responsible Party :  
 
 
Responsible Party SSN:  
 
 
 
  STEP 3: IF INSURANCE PROVIDED, ENTER INFORMATION BELOW  
     
 
Primary Insurance:  
 
 
Policy Number:     Group Number :  
 
 
Primary Insurance Phone #:  
 
 
Secondary Insurance:  
 
 
Policy Number:     Group Number :  
 
 
Secondary Insurance Phone #:  
 
  Note:   Tricare / Arkansas / Oklahoma Medicaid must have referrals prior to appt.  
 
 
  STEP 4 : IF WORKER'S COMPENSATION, ENTER INFORMATION BELOW  
     
 
Policy Number :  
 
 
Carrier :     Carrier Phone #:  
 
 
Employer:     Employer Phone # :  
 
 
DOA:     Claim Number:  
 
  Note:   We accept only Arkansas/Oklahoma worker's compensation  
 
 
  STEP 5 : IF OTHER FINANCIAL RESPONSIBILITY, ENTER INFORMATION BELOW  
     
 
Please describe:  
 
 
 
 

IMPORTANT NOTICE : We request the following patient information be faxed
to us at 479.709.7030 immediately following the submission of this form:

• Demographic Information
• Lab Work
• X-Rays
• Patient History

Upon successful processing of this form & the above indicated materials,
we will fax you an appointment confirmation detailing the date, time & physician.

 
     
 

All information submitted will be treated as highly confidential.

 
     
     
     
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