Physicians Referral Form

To refer a patient to a KCNMG physician or provider clinics, please complete the information requested below. This is a secure form, and the information you provide will enable us to assist your patient as efficiently as possible.

• Fax to 661.869.1834, Other Fax numbers can be found online at www.kernneuro.com.
• Or just simply use the SUBMIT/SEND button to send it to us directly.
• Include brief pertinent medical records, including test results that support the consultation.
• Include patients insurance card (both sides) and HMO authorization if required.
Referring Physician Office Information:
A KCNMG Referral representative will call the patient/contact person between 8:30am–5:00pm, Monday–Friday
Referring Physician
Phone
Practice/Clinic Name
Contact Person
Email
Address
Street Address City State / Province / Region ZIP / Postal Code
Patient's Information:
A KCNMG Referral representative will call the patient/contact person between 8:30am–5:00pm, Monday–Friday
Name
Birthday
If child, name of parent(s)
Landline
Phone
Preferred Provider
Visit Type
Diagnosis
Insurance:
A KCNMG Referral representative will call the patient/contact person between 8:30am–5:00pm, Monday–Friday
Insurance Name
Policy No. (Primary)
Subscriber
Policy No. (Secondary)
Subscriber
HMO Authorization
Comment
Insurance Card
Include patient’s insurance card (both sides) and HMO authorization if required.
o Faxed Medical Records and Insurance to 661.869.1834
o Emailed Medical Records and Insurance to kcnmg@kernneuro.com
Comments
This field is for validation purposes and should be left unchanged.

Patients and their physicians choose our neurologists because of their expertise in leading-edge diagnostic studies (EMG and NCV, EEG, Carotid Scan).

Introducing of pediatric neurologist Dr. Yawen Wang, MD

Physicians Referral Form

Referring Physician Office Information:

Patient's Information:

Insurance:

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