Patient Consult Request Form

• Eligible insurance for the patient

• Patient contact information and address

• Caregiver/Family member contact information

• PCP information

• Medical records

• Copy of insurance card

• Place of service

Fax consult request to Med Source Consultants, including consult request, patient demographics, and all supporting clinical documentation.

Fax: 786-828-7131

Phone: 786-8287221

Mobile: 305-975-7774