Referral Form
Questions? Call or text Baton Rouge Cardiology Center at (225) 769-0933.
Referring Provider Information
Referring Provider Name
*
First Name
Last Name
Suffix
Practice Name
Referring Provider Email
Office Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Provider Phone
*
Please enter a valid phone number.
Referring Provider Fax
Please enter a valid phone number.
National Provider Identifier (NPI)
Primary Care Provider (optional)
*
First Name
Last Name
Suffix
Patient Information
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
BRCC Number
Patient Email (optional)
example@example.com
Sex (Assigned at Birth)
*
Male
Female
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Other Phone
Please enter a valid phone number.
Patient Insurance Information (if available)
*
Appointment Request
Reason for Referral - Indication or Diagnosis
*
Specialty Requested
Cardiology
Interventional Cardiology
Electrophysiology
Vascular/Vein
Other
Provider & Location Preferences
Physician Requested
No Preference
Darrin M. Breaux, M.D., FACC
Joseph M. Cefalu, M.D., FACC
Harold G. Clausen, M.D., FACC, FSCAI
Daniel T. Fontenot, M.D., FACC
Boyd E. Helm, M.D., FACC, FSCAI
Steven E. Kelley, M.D.
Benjamin E. Kilpatrick, M.D.
Kevin L. Kilpatrick, M.D., FACC
Lance C. LaMotte, M.D., FACC
Steven A. Malosky, M.D., FACC, FSCAI
Nakia A. Newsome, M.D., FACC
Henry C. Patrick, M.D., FACC
Fred H. Petty, M.D., FACC, FSCAI
Mark S. Pollet, M.D., FACC
Evens Rodney, M.D., FACC
Venkat R. Surakanti, M.D., FACC, FSCAI
Terry L. Zellmer, M.D., FACC
Preferred Office Location
No Preference
Baton Rouge, LA (Brittany Dr.)
Baton Rouge, LA (Summa Ave.)
Baton Rouge, LA (Mid City)
Brusly, LA
Centreville, MS
Denham Springs, LA
Donaldsonville, LA
Gonzales, LA
Lutcher, LA
New Roads, LA
Prairieville, LA
St. Francisville, LA
Walker, LA
Woodville, MS
Zachary, LA (Hwy. 19)
Zachary, LA (Old Scenic Hwy.)
Other
Documents
Submit any pertinent medical records. Fax documents to 225-769-6255.
Completed referral form
Demographics sheet
Insurance card (copy front & back)
History and Physical Examination (H&P)
Laboratory results
Electrocardiogram (EKG)
Other studies (report & images on CD)
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