Referral Information by Clinic

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral
• Medication List
• Past note which highlights or includes the reason for the visit and/or size of site.
• Patients will be scheduled with first available provider unless specific provider is noted.

If a biopsy has been performed, please include:

• Pathology results
• Any photos when applicable.

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax:
  • (406) 455-4052 - Dr. Jonathan Bingam, Katie Brown, PA-C
  • (406) 455-2798 - Dr. Nicole Donester, Dr. Leslie Stapp, Courtney Forde, FNP, Casey Barker, FNP

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient. **Referrals received are reviewed by provider for approval. This process can take up to 2 weeks. If approved, scheduling will contact patient for an appointment.**

Referral Requirements to be present on electronic referral:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral
• H&P within last 90 days

Adrenal / Addison’s disease:

• Lab work within the last year.
  • ACTH
  • AM Cortisol Levels
  • BMP/CMP
  • If ACTH or Cortisol are low may need cortisol stim test (cosytropin stim test)
  • Previous Stim test
• Diagnostic tests within the last year
• Outside notes within the last year

Diabetes:

• Lab work within the last year
  • Hemoglobin A1c
  • CMP
  • Urine Microalbumin Creatine Ratio
• Outside notes within the last year, include additional notes if pertinent

Thyroid (Hyper/Hypo):

• Lab work within the last year
  • TSH
  • T3, T4, Free T3, Free T4, Thyroid antibodies (if available)
• Diagnostic tests within the last year
  • Thyroid Ultrasound
  • Fine Needle Biopsy
• Outside notes within the last year, include additional notes if pertinent

Parathyroid

• Lab work within the last year
  • Calcium
  • PTH
  • BUN/Creat
• Diagnostic tests within the last year
  • Nuclear Med Scan
  • Ultrasound
  • CT scan
  • DEXA scan
• Outside notes within the last year, include additional notes if pertinent

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 731-8838

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient. Referral Requirements to be present on referral:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Most recent and complete H&P
• Urgency of Referral

The following are suggestions of information to be sent with referrals for specific diagnoses:

Sinus:

• Send any CT reports and push imaging to PACS
• Operative reports/surgical history

Thyroid:

• TSH
• Ultrasound reports, biopsy pathology reports
• Outside notes from Endocrinology or outside specialist/surgeon

Parathyroid:

• Labs: Calcium, PTH, kidney function (BUN/Creat.), 24hr urine
• Ultrasound report, sestamibi scan
• Outside notes within the last couple years including surgical reports

Ears (Hearing loss, ear infections, dizziness):

• Previous audiogram

Cancer:

• Labs, medication list
• Oncology/Radiation oncology notes
• Most recent imaging (CT/MRI/PET)

Voice problems/cough/dysphagia:

• Send EGD/esophagram results, if performed

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 731-8341

Referral is not required.

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient. Referral Requirements to be present on referral:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Most recent and complete H&P
• Urgency of Referral

The following are suggestions of information to be sent with referral:

Imaging/Diagnostic:

• Colonoscopy
• DEXA
• Mammogram
• Any other recent or relevant diagnostic/imaging.

Immunization Records, if not available on the Montana State Immunization Registry.

Laboratory:

• Labs within the last year

   

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 731-8031

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements to be present on referral:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral
• H&P within last 30 days

Hepatitis C:

• Lab work within the last 6 months
  • Hepatitis panel, RNA genotype, fibrosis panel
• Patient must be sober 6 months or more
• Outside notes within the last 6 months

Cirrhosis/elevated liver function test:

• Lab work within the last 6 months
  • CBC with diff, CMP and Pt/INR
• Liver ultrasound within last 6 months
• Outside notes within the last 6 months

Pancreatitis:

• Lab work within the last 6 months
  • CBC with diff, CMP, Pt/INR, amylase, and lipase
• CT or MRI of the pancreas within 6 months
• Outside notes within the last 6 months

Pancreatic cyst/mass:

• Lab work within the last 3 months
  • CBC with diff, CMP, Pt/INR, amylase, lipase, and CA19-9
• CT or MRI of the pancreas within 3 months
• Outside notes within the last 6 months

GI Bleed (upper and lower):

• Lab work within the last 6 months
  • CBC with diff, CMP and PT/INR
• Diagnostic tests within the last year
  • Colonoscopy, EGD
• Outside notes within the last year

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 731-8389

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient. Referral Requirements to be present on referral:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Most recent and complete H&P
• Urgency of Referral

The following are suggestions of information to be sent with referrals for specific diagnoses:

Laboratory:

• Labs for the past 12 months.

Diagnostic and Imaging:

• Relevant imaging withing the past 12 months.

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 455-4977

By following the guidelines and submitting a complete order, you will help us schedule your patient in a timely manner and ensure a productive and smooth infusion for your patient.

Order Requirements:

• Patient Demographic Information
• Insurance Information copy of cards, if available
• Prior Authorization completed and ready for patient to be scheduled, if possible
• Complete Order (please do not write on prescription paper it makes the order illegible)
  • ICD-10 Diagnosis
  • Drug
  • Dose
  • Route
  • Frequency
  • Provider Signature and date

Laboratory Requirements:

• Lab work results within last 3 months

Please send order:

• Electronically, if within Benefis
• By Fax: (406) 731-8834

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral is required before scheduling, no self-referrals.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral

Laboratory Requirements (within the last year):

• Serial Creatinines
• Previous UA’s
• Chemistry Panel
• 24-hour Urine
• CBC

Imaging/Diagnostic Requirements:

• Previous CT and/or US Kidney Imaging within the last year, if possible.

Additional Information:

• Detailed medication list, including NSAID use.
• Any additional pertinent information.

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 771-6805

Referral is required before scheduling, no self-referrals.

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral
• H&P within last year

Memory Loss:

• Diagnostic tests within the last year.
  • If under 60 years old, an EEG if available.
• Outside notes within the last year

Migraines:

• Needs to have tried and failed 2 classes of prophylactic agents before referring (examples: Beta Blockers, Topamax or Depakote, and Amitriptyline or Venlafaxine)
• Outside notes within the last year

Neuropathy:

• Lab work within the last year
  • Hemoglobin A1C, Vitamin B-12, Folate, CMP
• Diagnostic tests within the last year.
  • EMG
• Outside notes within the last year

Seizures:

• Diagnostic tests within the last year
  • EEG, MRI brain
• Outside notes within the last year with medication history

PLEASE NOTE WE ARE UNABLE TO EVALUATE OR TREAT THE FOLLOWING CONDITIONS:

• Carpal tunnel syndrome
• Syncope
• Pseudo seizures/non-epileptic seizures
• TIA/Stroke hospital follow ups
• Low back and neck pain
• Radiculopathy
• Occipital neuralgia
• Musculoskeletal pain
• Dizziness
• Primary psychiatric disorders
• Patients already established with another neurologist

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 731-8651

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral

Laboratory Requirements:

• Diabetic Patients: Hemoglobin A1C within last year - provider prefers < 7

Imaging/Diagnostic Requirements:

• MRI, CT within the last 8 months
  • If unable to obtain MRI, then CT Myelogram
• EMG and results, if appropriate for diagnosis

Additional Information:

• What, if any, conservative measures have been tried, i.e. PT, injections, chiropractor, Medrol dose pack, NSAIDS, pain meds, etc.
• Past neurosurgery or spine surgery and by whom

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax:
  • Dr. Brandvold (406) 731-8341
  • Dr. Schaefer (406) 454-0377

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral

Concussion:

• Outside notes if seen in another facility
• Any prior testing
• Impact testing if applicable

Fracture:

• Imaging (X-rays, MRI’s, etc.)
• Outside notes

Joint Pain:

• Any prior imaging
• Outside notes if seen at another facility

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 455-3695 or (406) 455-3668

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 455-2373

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral
• H&P from last visit

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 455-2161

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral

Additional Information:

• Patients can also self-refer by calling (406) 455-2760

  Please send referral:

  • Electronically, if within Benefis
  • Via secure direct address
  • By Fax: (406) 455-2769

By following the guidelines and submitting a complete order, you will help us schedule your patient in a timely manner, match them with the right therapist and ensure a productive and smooth first appointment for your patient.

Order Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen – Therapy Related ICD-10
• Urgency of Referral
• Most recent Clinical Documentation
• Provider Signature / Date
• Insurance Authorization initiated if required (Tricare, VA, Workman’s Compensation)

Imaging Requirements:

• Any recent diagnostic results associated with referral Diagnosis

Additional Information:

• Please specify discipline being requested PT/OT/SLP

Please send order:

• Electronically, if within Benefis
• By Fax:
  • MOB4 Therapy Center (406) 731-8935
  • PEAK Therapy Center (406) 455-4452
  • Evergreen Therapy Center (406) 455-4996
  • Pediatric Therapy Center (406) 455-2626

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Insurance Authorization
  • VA, MAFB, Work Comp, etc.
• Referring Provider, Primary Care Provider
• Active medication list.
• Reason for Being Seen
  • Please specify “Medication Management” or “Evaluate for Interventional Procedures”.
  • Be specific as to location of pain and the condition.

Laboratory:

• Labs for the past 12 months.

Diagnostic and Imaging:

• Relevant imaging within the past 12 months.
• Sleep study, if available.
• Any neuro/psych testing.

Additional Information:

• Any conservative measures that have been tried, i.e., physical therapy, massage, chiropractor, injections, NSAIDS, pain medications, etc.
• Hospital/Urgent care visit notes (pertaining to referral).
• Any previous pain related treatments or providers.
• Any information regarding breach of pain contract or aberrant drug related behavior.

Please send referral:

• Electronically, if within Benefis.
• Via secure direct address
• By Fax: (406) 455-2141

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements to be present on referral.

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral
• H&P from most recent visit with reason for referral
• In the event they are transferring care from another endocrine provider, please provide as much information as possible from previous treatment and subspecialties

Diabetes/Prediabetes:

• Lab work within the last year
• Diagnostic tests completed related to diagnosis or within last year
• Outside notes (primary physician and specialty) within the last 1 year

Short Stature/Growth Concerns:

• Lab work within the last 6 months – year if available
• Diagnostic tests within the last year
• Outside notes within the last year from specialties
• Primary provider notes with growth chart

Precocious Puberty:

• Lab work within the last 6 months – year if available
• Diagnostic tests within the last year
• Outside notes within the last year from specialties
• Primary provider notes with growth chart

Other Endocrine concerns (i.e. obesity/failure to thrive, etc.):

• Lab work within the last 6 months - 1 year
• Diagnostic tests within the last 1 year
• Outside notes within the last 1 year related to diagnosis – with growth charts – Height weight and BMI

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 731-8874

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Prior Authorization
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral
• H&P (within last 12 months)

Laboratory:

• Any recent labs

Diagnostic/Imaging:

• Any relevant imaging available.
• Recent EKG, if available.

Additional Information:

• It is helpful to include any recent visit notes from Cardiology, Neurology, or relevant specialties that are outside of Benefis.
• Please send referral:
  • Electronically, if within Benefis.
  • Via secure direct address
  • By Fax: (406) 455-2871

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral

Laboratory Requirements:

• None

Imaging Requirements:

• None

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 761-7219

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

We accept referrals for COPD, Asthma, lung nodules, pulmonary fibrosis, pulmonary sarcoid, lung cancer, and other pulmonary disorders. We do not specialize in sleep disorders, please send these referrals to Benefis Sleep Medicine.

Age Range: We do not accept patients under the age of 12 years old at this time.

Once the referral is received, the provider will review the information and may schedule the evaluation with some additional testing that we can coordinate in our office to have done the same day as the appointments being scheduled.

Please do not try to schedule any of these tests from your office at time of referral, as it can delay the process due to having to wait for the results before the patient can be evaluated by the provider.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral
• H&P within the last year
• Medication List

The following are suggestions of information to be sent with referrals:

Diagnostic/Laboratory:

• Lab work/results with in the last 2 years
• Any previous pulmonary testing, such as: Spirometry, complete PFT, or methacholine results

Imaging:

• Most recent chest x-ray report and images pushed to Benefis PACS system (with in the last year)
• Most recent chest CT report and images pushed to Benefis PACS system (with in the last 2 years)

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 731-8359

Spirometry with Bronchodilator Challenge:

• Diagnosis for testing
• Provider Signed Order
• Performed on ages 12-90 years
• Testing takes approximately 30 minutes

Complete Pulmonary Testing:

• Diagnosis for testing
• Provider Signed Order
• Performed on ages 18-90 years
• Testing takes approximately 60 minutes
• Patients most recent weight
  • Please note, maximum weight for this test is 350 lbs. and unfortunately cannot be performed on patients that are wheelchair bound

Methacholine Testing:

• Only performed at the hospital PFT lab. Please fax order to (406) 455-4190

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider
• Reason for Being Seen
• Urgency of Referral
• H&P from the most recent visit
• Chest CT Order (chest/lung screen ordered in Nextgen)

Patient Age:

• Must be between 55 and 77 years of age

Patients smoking history, please document the following:

• Are they a current smoker?
• How many years smoking?
• How much smoking on daily average?
• Were they a former smoker; include year quit?
• Any symptoms of lung cancer?
• Did provider discuss lung cancer screening (part of “shared decision making”)?
• Did provider counsel on smoking cessation?
• Does the provider want follow up scheduled after the chest CT?
• Questions can be answered by Lung Cancer Nurse Navigator at (406) 731-8293

Please send referral:

• Electronically, if within Benefis
• By Fax: (406) 455-3152

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Urgency of Referral
• Office note from last 3 months

Laboratory Requirements (within past 90 days):

• Rheumatoid Factor
• Sedrate
• C Reactive Protein
• Anti CCP
• ANA Profile (not the screen)

Imaging Requirements:

• None

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 731-8839

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information copy of cards if available
• Referring Provider, Primary Care Provider
• Reason for Being Seen dictated in office note within last 3 months
• Urgency of Referral
• Completed Order Set (attachment)

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax:
  • Sleep Study and Overnight Pulse Ox (406) 731-8839
  • Dr. Roux (406) 731-8838

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Physician Notes
• Medication List
• Health History H&P
• Urgency of Referral (per provider referring)

Genetics

• Any supporting documentation if available.

Hematology

• Evidence of serial lab testing.
• Lab work associated with reason for referral.

Oncology

Imaging/Pathology

• Pathology and/or associated lab work (i.e.: myeloma, MDS)
• Imaging reports and PACS

Additional Information

• Any pending studies (staging, biopsy, etc.,)
• Any ending referrals to other specialties
• Any records from outside facility related to cancer care of diagnosis

Triage Process

• All referrals are triaged by a patient navigator. We will call your patient with appointment and next steps.

Additional Information

• Survivorship patient will be assigned to midlevel provider at this time.
• Please keep in mind that Sletten is on a different EHR platform than the rest of our hospital.
• Our infusion area is intended for the administration of hematology/oncology related treatments.

Please send referral:

• By Fax: (406) 455-2685

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Requirements to be present on electronic referral:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Most recent and complete H&P
• Urgency of Referral

Please send referral:

• Electronically, if within Benefis
• Via secure direct address
• By Fax: (406) 731-8001

By following the guidelines and submitting a complete referral, you will help us schedule your patient in a timely manner, match them with the right specialist and ensure a productive and smooth first appointment for your patient.

Referral Information:

• Patient Demographic Information
• Insurance Information
• Referring Provider, Primary Care Provider
• Reason for Being Seen
• Physician Notes
• Medication List
• Health History H&P

Please send referral:

• By Fax: (406) 455-2685