Physician Referrals

Dr. Mantas welcomes physician referrals from all doctors who are in need of expert gastrointestinal services. His facilities including clinic office, out-patient endoscopy centers and hospital gastrointestinal labs are state of the art and he and his staff are prepared to handle the full spectrum of gastrointestinal disease with the utmost care and compassion.

Dr. Mantas strives to schedule your patients as soon as possible and maintain a daily appointment slot for urgent cases. Following their appointment patients are given private access to the Digestive Wellness Center providing them with a wealth of knowledge on their gastrointestinal disease.

Dr. Mantas works very closely with all his referring doctors and keeps all involved health care providers apprised of their patient’s clinic visit, endoscopy and pathology reports and overall progress with same day detailed reports faxed to their office.

Dr. Mantas is deeply appreciative of your referral and honored to be given the trust in taking care of your patient. If you are physician or referral coordinator and would like to refer one of your patients to Dr. Mantas please download our referral form and fax to (214/972) 617-2000 or fill out the online referral request below and click send. In addition please fax over all pertinent office notes, prior procedure reports with pathology, imaging reports and labs to our office at (214/972) 617-2000.

Physician Referral Form

Disclaimers

I understand that if any of the insurance information I have provided is incorrect or if I fail to notify the office of any insurance changes that I am responsible for all physician charges and non-covered medical services.

I hereby authorize the release of any medical information necessary for the process of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Alexander Mantas, MD, PA, Digestive Health Associates of Texas, PA and Digestive Health Management Endoscopy Centers. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid as an original. I have received the Notice of Privacy Practices.

By Submitting This Form, Patient Agrees To All Terms, Conditions & Disclaimers!

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Physician Referrals

Appointment Request

Full Legal Name

Gender

Date of Birth

Email Address

Home Phone Number

Mobile Phone Number

Office Phone Number

Prior GI Work Up

Select Requested Procedure(s)

If Yes, please briefly describe your work up including all previous procedures and their dates and the gastroenterologist who treated you.

Referring Doctor (If Self Referral, Please Type "Self")

Primary Care Doctor

Primary Insurance Provider

Reason For Office Visit

Disclaimers

By Submitting This Form, Patient Agrees To All Terms, Conditions & Disclaimers!

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