Orleans Parish Medical Society

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Physician Referral Service

Physician Referral Participation Needed
Medicaid and Medicare Providers in Demand

OPMS receives daily requests for physician referrals and an increasing number of these are requests for Medicaid/Medicare providers. If you would like to be part of the OPMS referral data base, please fill out both sides of the following Physician Referral Participation Form. Please indicate in Patient Preference if you accept Medicaid/Medicare payments.

Questions? Call Susan D'Antoni at 523-2474, Ext. 3010

[Online Form ... in progress ]
Please complete this form, print and fax it to 522-3325.

Name:

Office (primary) Address:

Telephone:

Office Hours:

Days Away from Office:

Secondary Office Address:

Telephone:

Hours:

Days Away From Office:

Type of Practice:

Sub-Specialty:

Hospital Appointments:

Foreign Languages Spoken:

Referrals Will Be Seen In (select all that apply):
OFFICE HOSPITAL HOME Choice of Patients (select all that apply):
MALE FEMALE ADULTS CHILDREN GERIATRIC MEDICARE MEDICAID WELFARE OTHER:

Do You Accept Assignments?
YES No

If requested by the patient, the following information may be given: Medical School:

Year Graduated:

Residency and Graduate Training:

Religion:

Nationality:

Other Information:

Board Certified:

Dated signature must be mailed or faxed to OPMS for file.