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mc0688 04
mc0688 04
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Referral to Mayo Clinic
Form content retained in medical record.
Route to HIMS Scanning.
State (required for domestic patient) ZIP Code (required for domestic patient) NPI Number (required for domestic patient)
Phone Fax Primary Care Provider Name (First, Middle, Last) (optional)
Patient Information
Patient Name (First, Middle, Last) Birth Date (mm-dd-yyyy) Mayo Clinic Number
State (required for domestic patient) ZIP Code (required for domestic patient) Country (optional)
Patient Insurance Information (if available) Does the patient need an interpreter? If “Yes,” what language?
Yes No
What is the request related to? Motor vehicle accident Litigation Workers’ compensation Not applicable
Appointment Request
Clinical question to be answered. Submit any pertinent medical records.
Indication or Diagnosis
Specialty Requested
You will receive confirmation once the appointment is scheduled. To refer via our secure online portal,
visit www.mayoclinic.org/medical-professionals and click “CareLink online referrals.” KNEMCGKCGAGKMHC
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Thank you for referring your patient to Mayo Clinic. HFPAOCKKKCOAOPL
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