AFFZ11 Referral Form

Heads up: This form includes fields managed by your provider (marked with 🔒). Some appear empty — if you were expecting these to be pre-filled, please contact your provider for an updated form link.

DERMATOLOGY REFERRAL FORM

1. Office Location

Brookfield, WI

Waukesha, WI

New Berlin, WI

Germantown, WI

Oak Creek, WI

2. PATIENT DETAILS - Contact Information

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

📅

Date

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Sex

Male

Female

INSURANCE INFORMATION - *WE DO NOT ACCEPT MEDICAID HMO PLANS* WE DO ACCEPT SELF-PAY

Primary Insurance

Primary ID Number

To expedite your benefits confirmation, please attach a photo of the FRONT side of your PRIMARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

To expedite your benefits confirmation, please attach a photo of the BACK side of your PRIMARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

Do you have secondary insurance?

Yes

Secondary Insurance

Secondary ID Number

To expedite your benefits confirmation, please attach a photo of the FRONT side of your SECONDARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

To expedite your benefits confirmation, please attach a photo of the BACK side of your SECONDARY insurance card. You can use your cell phone to take the picture.

📎

Select Insurance Card Image

or drag and drop files here

Allowed: jpg, jpeg, png, gif (max 5 MB)

3. REFERRING PHYSICIAN - Contact Information

Name

First Name

Last Name

Phone Number

Please enter a valid phone number.

Fax Number

Please enter a valid phone number.

4. SCHEDULING

When do they need to be scheduled?

Urgent

Routine

5. REASON FOR REFERRAL

Diagnosis

Mohs

Lesion

Rash

Acne

Other

Body Location

Please fax this form and supporting documents including insurance cards to
(262) 754-4940
P: (262) 754-4488 | F: (262) 754-4940 | email: receptionist@affiliatedderm.com

Please complete the required fields

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