Get the free New Patient Intake/ Self-Referral Form - med stanford

Stanford Interventional Radiology 300 Pasteur Drive, MC 5642 Stanford, CA 94305 Phone: (650) 723-3893 Fax: (650) 736-7734 Website: www.ir.stanfordhospital.com INTERVENTIONAL RADIOLOGY New Patient

How to fill out new patient intake self-referral

How to fill out new patient intake self-referral?

1. Start by obtaining the necessary forms from the healthcare provider or downloading them from their website.
2. Read the instructions carefully to understand what information is required and how to complete the forms.
3. Provide personal information such as your full name, date of birth, address, and contact details.
4. Fill in your medical history, including any pre-existing conditions, medications you are currently taking, and previous surgeries or hospitalizations.
5. Answer questions about your insurance coverage or provide details of any medical plans you have.
6. If applicable, provide emergency contact information.
7. Review the completed form to ensure all required fields are filled in accurately.
8. Sign and date the form at the designated area.

Who needs new patient intake self-referral?

1. Individuals who are seeking medical care from a specific healthcare provider may need to complete a new patient intake self-referral.
2. Patients who have not been previously seen by the healthcare provider or have not visited them within a certain period may be required to fill out the self-referral form.
3. This form may be necessary for patients who are self-referring themselves to the healthcare provider without a referral from their primary care physician or other healthcare professional.

For pdfFiller’s FAQs

What is new patient intake self-referral?

New patient intake self-referral is a process where a patient initiates their own referral to a healthcare provider without the need for a physician's direct recommendation.

Who is required to file new patient intake self-referral?

Any patient who wishes to seek medical care from a specific healthcare provider can file a new patient intake self-referral.

How to fill out new patient intake self-referral?

To fill out a new patient intake self-referral, the patient needs to provide their personal information, reason for seeking care, desired provider, and any relevant medical history.

What is the purpose of new patient intake self-referral?

The purpose of new patient intake self-referral is to give patients the autonomy to choose their healthcare provider without relying solely on physician recommendations.

What information must be reported on new patient intake self-referral?

The new patient intake self-referral form typically requires the patient's full name, contact information, preferred provider's name, reason for seeking care, and any relevant medical information.

When is the deadline to file new patient intake self-referral in 2023?

The deadline to file new patient intake self-referral in 2023 may vary depending on healthcare provider policies. It is advisable to check with the specific provider for their deadline.

What is the penalty for the late filing of new patient intake self-referral?

The penalty for the late filing of new patient intake self-referral may also vary depending on provider policies. It is recommended to review the provider's terms and conditions or contact their customer service for information regarding penalties.

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