Clover Medical Corp.

12134 Victory Blvd.
North Hollywood CA 91606
Tel 800-801-3022
Fax (818)927-2088

CLOVER MEDICAL CORP.

TREATMENT AUTHORIZATION / REFERRAL

Fax Results Back to:
Fax (213) 481-9944
Phone: (213) 481-9900
holymedicalcenter@gmail.com

Please Fax Form Prior To Referral

Patient Full Name DOB Patient Phone # Coverage Medicare

Insurance

Private (Cash)

Other

IOP Clearance

Rehab

Dual Dx

ADHC

Pre-Op w/Consult (w/Drug Scrn) X-Ray w/Consult Cortisone Injection w/Consult Other / Describe Protocol Refering DX

URGENT CARE 24 HOURS - WE NEVER CLOSE

SPECIALISTS

Note: Private consults and surgery done in facility.

Note: Medicare consults in facility, if surgery needed, in hospital

URGENT CARE.................................... Addiction Medicine Implants.................................................By Appointment Plastic Surgery...............................................(No Medicare),Thursdays 9am General Surgery...................................................................Tuesdays 10am Podiatry..............................................................................Wednesdays 9-5 Cardiology.............................................................Every Other Saturday 11-2 Dermatology............................................................One Saturday per Month Gastroenterology.............................(No Medicare), Weds 11am, Sunday 9am Subspecialty: Hepatology & HIV Colonoscopy / Endoscopy Chiropractic.........................................................(No Medicare) by appt only Orthopedics.......................................................................Tuesdays 9:30 am Pain Management...................................................Every Other Saturday 2-6 Internal Medicine................................................Monday-Thursday 2:30 -7:30 Ophthalmology...................................................................Wednesdays 4pm Pediatrics.............................................................................By Appointment Nutritionist......................................................(No Medicare),By Appointment 24 HOURS – WALK IN SERVICE

SERVICE

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Blood Draw- test(s) listed below Ultrasound w/Consult Specialist Consult(s)