Physician Referral Form

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Community News

EIght Locations with World Class Physicians serving the local community...

William Bauer, MD, PhD, FAAN
Board Certified Neurologist

Brendan W. Bauer, MD
Board Certified Neurologist
Board Certified Vascular Neurology

Steven Benedict, MD
Board Certied Neurologist
Board Certified Vascular Neurology

Nicole Baryiski Danner, DO
Board Certified Neurologist

Michael J. Leslie, MD, MS
Board Certified Neurologist
Board Certified Vascular Neurology

Iman Abou-Chakra, MD
Board Certified in Physical Medicine & Rehabilitation Pain Management

Community News...

www.stopthepainohio.com

Our pledge...

The mission of Advanced Neurologic Associates is to achieve value through the delivery of cost effective quality healthcare and the attainment of optimum patient outcomes within a regionalized system.

Physician Referral Form

Please fill out the information below. An appointment representative will call and confirm information and appointment time.

Please enter any comments or more detailed feedback here:
Referring Physician Email
Referring Physician Name
Patient First Name
Patient Last Name
Patient Address
Patient City
Patient State
Patient Zip code
Patient Home Phone
Patient Work Phone
Patient Cell Phone
Diagnosis
Insurance
Insuance Policy #
Group Name
Ploicy Holder Name if not the patient
Relationship to the Insured
Authorization
Please check the Physician you would like the appointment with	William Bauer, MD, PhD, FAAN Brendan Bauer, MD Steven Benedict, MD Nicole Baryiski Danner, DO Michael Leslie, MD, MS Iman Abou-Chakra, MD
Please enter any comments or more additional feedback here:

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