Maternal Fetal Medicine - NCWH

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UNC Department of Obstetrics & Gynecology

Online Physician Referral Form
Maternal Fetal Medicine at N.C. Women's Hospital




IMPORTANT INFORMATION:
Patient's Medical Records & Other Forms

The confirmation page will provide instructions for patient records & current insurance information.  Please review at that time.
PATIENT INFORMATION
Contacting patient   Does the patient know to expect a call from us for this appointment? If no, we will contact your office to schedule.


Interpreter Is an interpreter needed for the patient's visit


SPECIFIC REQUEST
REFERRING CLINICIAN INFORMATION
Preferred Method of Communication  




INSURANCE INFORMATION
Insurance Information   Select all that apply
E-MAIL DISCLAIMER FOR UNC HEALTH CARE AND ALL AFFILIATES
PRIVACY AND SECURITY UNC Health Care is concerned about the privacy of your medical information. Because conventional e-mail is inherently insecure, confidentiality of sensitive medical information cannot be assured. Therefore, sensitive medical matters should not be communicated through e-mail. Your e-mail messages may be processed by an assistant other than your clinician. Face-to-face or telephone communication should be used instead of e-mail to discuss sensitive medical matters. The reason that e-mail is not secure is because: * E-mail sent via the Internet or other external systems can be intercepted and read. * E-mail can be accidentally sent to the wrong recipient. * E-mail deleted by a user may still be accessed through backup files. * E-mail sent and received through work may be accessed by your employer. * E-mail can be altered to reflect an incorrect sender's address. * E-mail sent to a family account may be accessed by other family members. RESPONSES Because the response time to your message can be as long as two (2) working days, e-mail should not be used for urgent medical matters that require more timely attention. E-mail is best suited for straightforward medical issues such as prescription refill or appointment requests or cancellations. We want to make sure you have gotten our e-mail reply to you. Please acknowledge e-mail from us by using the "reply" feature on your e-mail. All correspondence to us and from us will be documented in your medical record. TYPES OF MESSAGES Because e-mail is best suited for non-urgent issues, you should use it for prescription refills, request or cancellation of appointments, or simple medical questions. Sensitive issues such as the results of HIV testing, substance abuse, or mental health issues will not be addressed by e-mail. For urgent matters, call 911. For less urgent matters that are best handled by the telephone or a face-to-face encounter with your clinician, call your provider's medical office.
Disclaimer and Notice of Privacy Practices and regarding the use of e-mail (Required)