| Pediatrics
Clinic - 1900 CentraCare Circle,
Suite 1300, St. Cloud, MN 56303
Patient_______________________
DOB_____________________MRN_____________
Dear Doctor:
As part of our Medical Home care coordination, we would greatly appreciate it if you could BRIEFLY outline your findings and concerns today, as well as your plan. If there are specific future labs you need from us, please include those. This is not meant to replace your letter to us, but to assist in getting pertinent information to us more quickly. Thank you so much for your help!
Date:________________________
Specialist:_____________________________
Phone/fax#:___________________________
Today’s concern and findings:
Plan:
Follow-up:
Please print this page and fax to (please circle health care provider name) at 320-654-3602.
| Debra Berglund, C.P.N.P. |
Jeffrey Humbert, M.D. |
Denise
Lenarz, M.D. |
Thomas
Schrup, M.D. |
| Christopher Brown, D.O. |
Janelle Johnson, M.D. |
Cindy
Melloy, M.D. |
Sylvia
Sundberg, M.D. |
| Jon Dennis, M.D. |
Wendi Johnson, M.D. |
Dale
Minnerath, M.D. |
David
Tilstra, M.D. |
| William Hicks, M.D. |
Mary Keating, M.D. |
Marilyn
Peitso, M.D. |
Dove
Watkin, M.D. |
| Weining Hu, M.D. |
Kathleen
Kulus, M.D. |
Minto Porter, M.D. |
|
If you have
questions or concerns about this
form, please call 320-654-3686. |
