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MEDICAL GROUP, INC.

  

 

 

 

EMERGENCY INFO

FOR PHYSICIANS

 Call local: 713-772-1300        Toll Free: 1-888-772-1330

HOME  |  ABOUT US  |  SERVICES  |  CONTACT US  |  F.A.Q

 

HOW TO CONTACT US

Our friendly staff carefully responds to every referral and appointment. To contact us, you

may reach us by these methods:

For Referrals: Please click here

Office Address: 10101 Harwin Drive Ste 260, Houston, TX 77036

Local telephone: 713-772-1300

Toll Free: 1-888-772-1330

FAX: 713-772-1310

E-Mail info@unifiedmedicalgroup.com

Website: http://www.unifiedmedicalgroup.com

EMERGENCY INFO

In the event of a medical emergency whether at

home or elsewhere, please call 911 immediately.

Physicians, Hospitals & individual Referrals

If you are a private Physician, a Hospital Rep., or individual who needs special care or follow-up for a loved one, you may refer your patients to us. Please click appropriate link below and fill out the form.
 

Physician Referral

Hospital Referral
Private Individual Referral

 
REFERRAL FROM PRIVATE PHYSICIAN

                                                      Patient's Information                  *Required Fields
Title: Mr. Mrs. Ms  
*First Name :  
*Last Name :  
Medicare :    ID# Group#
Medicaid :    ID# Group#
Private Ins.   ID# Group#
DOB :    Year:   
*Street Address :  
*City :  
*State :  
*Zip Code :  
*Phone :  
Email Address :  
             Physician's Information            *Required Fields
*Title:     
*Physician's Name :  
*Phone :  
Email Address :  
Does Patient Need an Interpreter?    
  No   /  Yes    Language:  
Patient Diagnosis :  
Procedure :  
Discharge Date :       
EVALUATIONS:    
Diabetes Home Care  
Heart Home Care  
Occupational Therapy  
Private Duty Aide  
Physical Therapy  
Rehab Home Care  
Skilled nursing  
Social Work  
Speech Therapy  
Patient's Medical History:
(Comments & specifications) 		 
     

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REFERRAL FROM A HOSPITAL

                                                     Patient's Information                     *Required Fields
Title: Mrs. Ms  
*First Name :  
*Last Name :  
Medicare :    ID# Group#
Medicaid :    ID# Group#
Private Ins.   ID# Group#
DOB :    Year:   
*Street Address :  
*City :  
*State :  
*Zip Code :  
*Phone :  
Email Address :  
        Hospital Information   *Required Fields
*Hospital's Name :  
*Attending Physician's Name :  
*Attending Physician's Phone :  
Case Manager's Name:
(In case we cannot reach Physician)		  
Case Manager's Phone:  
Case Manager's Title:  
Does Patient Need an Interpreter?    
  No   /  Yes    Language:  
Patient Diagnosis :  
Procedure :  
Discharge Date :       
EVALUATIONS:    
Diabetes Home Care  
Heart Home Care  
Occupational Therapy  
Private Duty Aide  
Physical Therapy  
Rehab Home Care  
Skilled nursing  
Social Work  
Speech Therapy  
Patient's Medical History:
(Comments & specifications) 		 
     

Back to the top

REFERRAL FROM A PRIVATE INDIVIDUAL

                                                    Patient's Information                    *Required Fields
Title: Mrs. Ms  
*First Name :  
*Last Name :  
Medicare :    ID# Group#
Medicaid :    ID# Group#
Private Ins.   ID# Group#
DOB :    Year: 
*Street Address :  
*City :  
*State :  
*Zip Code :  
*Phone :  
Email Address :  
       Referrer's Information       *Required Fields  
*Your First Name :  
*Your Last Name :  
*Home Phone :  
Cell Phone :  
Email Address :  
*Street Address :  
*City :  
*State :  
*Zip Code :  
Your Relation to the Patient?  
Does Patient Need an Interpreter?    
  No   /  Yes    Language:  
Patient Diagnosis :  
Procedure :  
Discharge Date :       
Patient's Medical History:
(Comments & specifications) 		 
     

Back to the top

 

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