Physicians Area

Referral Form

Thank you for referring your patient to us. In addition to this online request please fax us the following:

· 3 most recent labs(including any Urinalysis or 24 hour urine
· Reports of any Ultrasounds, MRI, X-Rays etc of the kidney
· Physicians Notes of last office visit
· Medication List and Pharmacy
· Demographic Sheet
· Copy of Insurance Cards
Please fax to :
Cary Office: 919-859-5813
Raleigh Office: 919-231-3912

Person completing form (required)

Your Email (required)

Give location option:

Referring Physician Information

Physicians Name (required)

Office Address (required)

Office Phone (required)

Patient Information

Patient Name (required)

Date of Birth (required)

Patient Address

Patient Phone (required)

Insurance Information

Primary Insurance Carrier

Policy Holder Name (if different from patient)

Policy # Group/Plan #

Is a referral required:  No Yes (Please Fax)

Is Authorization Required:  No Yes Authorization #
How Many Visits Expiration Date

Secondary Insurance Carrier

Policy Holder Name (if different from patient)

Policy # Group/Plan #

Is a referral required:  No Yes (Please Fax)

Is Authorization Required:  No Yes Authorization #
How Many Visits Expiration Date

Reason for Referral (required)

Any Special Instruction

Capital Nephrology Associates


Capital Nephrology Associates is a full service nephrology practice providing comprehensive state of the art diagnosis and treatment for kidney related diseases and hypertension. We also provide services for hemodialysis, peritoneal dialysis, renal transplantation referral, and followup. We have multiple locations, 11 physicians, and 2 physician assistants and 4 nurse practitioners to serve you. Our physicians are on call 24 hours a day, 7 days a week and admit to all the major hospitals in the Wake area. Our Locations
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