Physician Forms

COVID-19 FORMS

• COVID-19 Test Order Form

Specialty Forms

Diagnostic

• Cardio, Pulmonology, Neurology Services (Form 31938, Rev 9/20)

Infusion

• Abatacept (Orencia) Infusion (ADM 5245, Rev 10/20)
• Albumin Infusion (ADM 5220, Rev 10/20)
• Belimumab (Benlysta) Infusion (ADM 5225, Rev 10/20)
• Gammagard Infusion (ADM 5230, Rev 10/20)
• Gammunex-C Infusion (ADM 5235, Rev 10/20)
• General (Misc) Infusion (ADM 5260, Rev 10/20)
• Golimumab (Simponi Aria) Infusion (ADM 5250, Rev 10/20)
• Infliximab (Remicade) Infusion (ADM 5240, Rev 10/20)
• Methylprednisolone (Solu-Medrol) Infusion (ADM 5255, Rev 10/20)
• Rituximab (First Infusion) (ADM 5200, Rev 12/18)
• Rituximab (Subsequent Infusions) (ADM 5205 , Rev 12/18)
• Tocilizumab (Actemra) Infusion (ADM 5215, Rev 10/20)

Lab

• LAB AFTER HOURS ORDER FORM
• Outpatient Lab Orders (Form 31825, Rev 08/19)
• Supply Form (Form 31675, Rev 01/19)

Nutrition

• Outpatient Nutrition Order (Form 31770, Rev 09/17)

Radiology

• Outpatient Radiology Order (Form 30428, Rev 09/20)
• Outpatient Radiology Orders - Emory Center (Form 32891, Rev 10/20)
• Outpatient Radiology Orders - Sevier Outpatient Center (Form 32934, Rev 12/20)
• MRI Physician Order (Form 30403, Rev 12/20)

Rehabilitation

• Rehabilitation Referral Form (Form 32434, Rev 12/20)
• Motivating Mealtimes Physician Referral (Form 32467, Rev 07/19)

Sleep

• Request for Sleep Consultation (Form 30166, Rev 09/15)

Specialists - General

• Referral List and Map (Form 31829, Rev 08/19)
• Physiatry Referral Request (Form 31841, Rev 02/17)

Pediatric Surgery

• East Tennessee Pediatric Surgery Group Referral Request (Form 32869, Rev 10/20)

Medical Data

• 2020 Antibiogram

Regional Practice Forms

• Authorization for Release of Information (Form 30399, Rev 6/18)
• Privacy Notice: English (Form 31644, Rev 1/20)
• Privacy Notice: Spanish (Form 31645, Rev 1/20)
• In Loco Parentis Consent to Treat and Affidavit (Forms 31646 and 32179, Rev 6/20 and 7/18)
• Parent/Guardian Consent for Treatment (Form 31647, Rev 5/20)
• Adult Patient Consent for Treatment (Form 31648, Rev 8/19)
• Affidavit for Adult: Spanish (Form 31649, Rev 1/17)
• Patient Information for Regional Practices: English (Form 31654, Rev 4/20)
• Patient Information for Regional Practices: Spanish (Form 31655, Rev 4/20)
• Adult Patient Consent to Treat: Spanish (Form 31666, Rev 1/17)
• What Are My Patient Benefits: English (Form 31735, Rev 8/20)
• What Are My Patient Benefits: Spanish (Form 32855, Rev 9/20)
  
• Vaccine Policy for Practices: English (Form 32257, Rev 9/20)
• Vaccine Policy for Practices: Spanish (Form 32856, Rev 9/20)