Patient Referrals - New South Medical

REFERRING PROVIDERS

Please complete the contact form below and submit it to us. You can also download the attached PDF form, fill it out, and send it directly to our email address below. If you have any questions, don’t hesitate to call.

Email: referrals@newsouthmedical.com

Email: (770) 993-1000

Patient Name

Patient Email

Patient Phone number

Patient Address

Attorney

Attorney Contact #

Case Manager

Referring Physician

Referring Physician Contact #

Diagnosis

ICD 10

Reason for Referral

Does the patient have imaging?

If YES, please attach imaging impression reports to this referral. If NO, we will still evaluate the patient and order imaging if necessary.

Patient is Currently Receiving:

Please attach patient auto insurance policy, contact information, case number, contact agent and health insurance if applicable. Also attach police report and any hospital records.

New South Medical will email the referring physician a confirmation of the date, time and location for your client to be evaluated. After the client is evaluated and managed by the medical team, an encounter note will be emailed to the referring physician's email address listed above. This will allow for an integrated approach to helping your client achieve the best results.

PLEASE EMAIL REFERRAL TO: referrals@newsouthmedical.com
New South Medical Administrator: (770) 993 - 1000 — Please call if you have any questions.

Attach Case Documents (Insurance, Police Reports, Hospital Records, etc.)