Becoming a Patient

Physician's Referral Form for New Patients

Thank you for your interest in the Myeloma Institute at the University or Arkansas for Medical Sciences. Please complete the following form. We will contact you within 24 hours (excluding holidays and weekends) of our receipt of this information. All information is secure via standard encryption technology.

The "New Patient" Referral Office is open Monday through Friday from 8:00 a.m. to 5:00 p.m. CST. If you are in the USA or Canada, you can call us toll-free: 1-888-MYELOMA (1-888-693-5662). Alternately, you can reach us worldwide at: 001-501-686-7105.

Referring Physician Information:
First Name:
Middle Name:
Last Name:

Office address:
Street Address:
Add country code if not in USA or Canada and extension if available:
Office phone:
Office fax:
Physician E-mail:
Primary Care Physician Name
Primary Care Physician 
Phone Number

Patient Information:
First Name:
Middle Name:
Last Name:
Date of Birth: MM/DD/YYYY
Gender: Male Female
Marital Status
Name of Spouse
Street Address:
Daytime phone:
Evening phone:

Employment Information:
Employer's Name: 
Employer's Street Address:
Employer's City:
Employer's State:
Employer's Zip:
Employer's Phone:

In Case of Emergency Contact: 
Emergency Contact Name:
Emergency Contact Phone:
Emergency Contact's 
Relationship to Patient:

Insurance Information:
Insurance Carrier:
Claims Mailing Address:
Benefits Phone Number:
Pre-certification Phone Number:
Subscriber Name:
Subscriber Date of Birth:
Subscriber SSN: 
Subscriber ID #:
Subscriber Group #:
Employers's Group Name:
Effective Date:
Patient's Diagnosis:
Diagnosis Date: MM/DD/YY
Diagnosis Method:
Specify if other:

Patient's Treatment Information:
Is the patient currently under treatment? YES NO
Treatment Method:
Specify if other:
Recent Hospitalization? No Yes
Date of Hospitalization: MM/DD/YYYY

Patient's Referral Information:
Are you referring to a specific physician? YES NO
Physician Name(if yes):

Your patient will also be contacted in order to review insurance coverage and obtain additional demographic information. Medical and financial eligibility will need to be established prior to confirming an appointment. If you would like to send an additional  message for the New Patient Referral Office, please type it here.

One of our Referral Specialists will call your office to discuss this referral further and to obtain additional information pertinent to this patient. Please indicate the contact person who can best assist with this referral.

First Name:
Last Name:
Contact Title:
Daytime Phone and Extension:

All e-mail or web Referral Forms will receive a phone response within 24 hours excluding weekends and holidays. The New Patient Referral Office is open Monday through Friday from 8:00 a.m. to 5:00 p.m. CST. If you are in USA or Canada, you can call us at: (1-888-MYELOMA or 1-888-693-5662). You can call us from anywhere at: 501-686-7105. Also, you can send a fax to 501-526-5906.