Information for Referring Providers - Dermatology Healthcare Excellence

Dear Colleagues,
It is my honor and privilege to be entrusted as a partner in caring for the skin health of your patients. At Dermatology Healthcare Excellence (DHE), my team and I are committed to providing timely, appropriate, and compassionate dermatologic care for your patients, and streamlined, personal, and reliable communication for you. Medical and surgical patient referrals can easily be made using a short form on our website or by faxing or emailing us the information. For every patient seen you will receive follow-up communication from me detailing the visit. When patients are sent to me specifically for surgery, you can be confident that I respect your role as the patient’s primary skin caretaker and will not appropriate the patient and overstep boundaries. If you have an urgent or complicated patient that requires immediate attention, I am only a cell phone call away. Whatever the reason, I am happy to be part of your team and look forward to working with you to take the best possible care of your patients.
— Salud! Dr. Basak

Ways to Make a Referral

Submit the Form
Fill out and submit the form below.
Email Us
Email the referral information to our HIPAA-secure email address at info@DHEskincare.com
Fax Us
Fax the information to our HIPAA-secure fax number at (720) 856-6117

Required Information

Information we need when making the referral:

Reason for referral
Office note
Pathology report, if relevant
Biopsy or lesion photos, if applicable
Patient demographic information
Patient insurance information

Provider Referral Form

Patient Information

Patient Name(Required)

First Last

Date of Birth(Required)

Phone(Required)

Email(Required)

Insurance Information

Primary Insurance Provider(Required)

Policy Number(Required)

Group Number(Required)

Reason for Referral

Medical/General Dermatology

Diagnosis/ Reason: (E.g. psoriasis/Rash/Changing mole/New Growth/Etc.)

Mohs Surgery

Tumor Type (E.g. SCC/BCC/Etc.)

Location

Excision

Lesion (E.g. cyst/lipoma/SCC/Etc.)

Location

Other

Details

Referring Provider Information

Provider Name(Required)

First Last

Provider Direct Phone

Please note: Dr. Basak, and ONLY Dr. Basak, will use this number if necessary to clarify or facilitate patient care. If your provider prefers, this info can be emailed directly to Dr. Basak at DrBasak@DHEskincare.com.

Phone Provided

Check if Dr. Basak already has provider's cell #

Office Phone(Required)

Office Fax

Attachments

Enter up to 10 attachments, such as photos, pathology report, office notes or additional patient demographic or insurance information. Image and document types are supported.

File

Drop files here or

Accepted file types: jpg, jpeg, png, webp, pdf, doc, docx, zip, Max. file size: 50 MB, Max. files: 10.