Referral | Fivestar Pulmonary Associates

Patient Name *

Email *

Location for Patient's Appointment

Allen

Plano

Reason for referral *

Type of Test Requested *

Full PFT with Body Box

Full PFT with Body Box + Pulm stress/exertion

Sleep Apnea Consultation

Bronchoscopy Consultation

Other info if applicable (eg. claim #, insurance carrier name, employer name at time of injury, general notes)

Who is referring the patient? *

EZ Comp

Case Manager Name *

Email (This is where we send the notes) *

Phone # *

Authorization # if available

Make Payment

Confirmation: I have completed the pre-payment via the link above *

Yes

No

Choose file

Have Questions?

Emails:
phone@fivestarpulm.com
admin@fivestarpulm.com
Phone:
972-526-0007

WC Insurance Adjuster

Adjuster Name *

Email *

Phone # *

Claim # *

First Report of Injury *

Employer Name *

Insurance Carrier *

Choose file

Additional Notes/Comments

Have Questions?

Emails:
phone@fivestarpulm.com
admin@fivestarpulm.com
Phone:
972-526-0007

**Fivestar Pulmonary Associates bills insurance carriers at our standard specialty rate (typically 95% of the Texas DWC MAR). Actual reimbursement is determined by the specific contract between this facility and your insurance provider or network**

Law Firm

Name of Firm *

Attorney/Case Manager *

Phone # *

Email (This is where we send the notes if no available portal) *

Please select your package *

Tier 1: Standard Diagnostic Package: $615.00

Tier 2: Standard Diagnostic + Pulm Stress Package: $695.90

Tier 3: Sleep Apnea Diagnostic Suite: $650

Follow-up "Evaluation Only" visits (without full diagnostics) : $200

***Is the claimant reporting symptoms only at rest, or do they have shortness of breath when walking/working? If it's the latter, we recommend the Comprehensive $695 Tier 2 .

MAKE PAYMENT

Confirmation: I have completed the pre-payment via the link above *

Yes

No

Choose file

Upload FileChoose file

Additional Notes/Comments

Have Questions?

Emails:
phone@fivestarpulm.com
admin@fivestarpulm.com
Phone:
972-526-0007

Medical Practice/Hospital

Referring Provider Name *

Referring Provider NPI *

Practice/Hospital Name *

Address *

Office Staff Name *

Office Staff Email *

Office Staff Phone # *

Insurance Type

Commercial

Medicare

Cash/Self Pay

Worker's Comp

Choose file

Have Questions?

Emails:
phone@fivestarpulm.com
admin@fivestarpulm.com
Phone:
972-526-0007

Occupational Medicine

Staff Name *

Phone # *

Email *

Claim # if applicable *

Date of Injury *

Pre Authorization # *

Date of Injury *

Insurance Type *

Commercial

Medicare

Cash Pay/Self Pay

Worker's Comp

Choose file

Have Questions?

Emails:
phone@fivestarpulm.com
admin@fivestarpulm.com
Phone:
972-526-0007

**Fivestar Pulmonary Associates bills insurance carriers at our standard specialty rate (typically 95% of the Texas DWC MAR). Actual reimbursement is determined by the specific contract between this facility and your insurance provider or network**

Fivestar Pulmonary Referral Form

Patient Information