Get the free Specialty Referral Form 013014

Specialty Office Referrals Please Fax to: BREATH: 8666035534 Contact Person: Phone Number: Member Name Member ID # Referring Provider Specialty Providence/TIN # Diagnosis (ICD9 code if available)

How to fill out specialty referral form 013014

How to fill out specialty referral form 013014:

1. Start by including the patient's personal information such as their name, date of birth, address, and contact information.
2. Provide the primary care physician's details, including their name, address, and phone number.
3. Indicate the reason for the referral and state the specialty or subspecialty being referred to.
4. Enter the date on which the referral was made.
5. Provide any relevant medical history or previous treatments undergone by the patient.
6. Include any specific tests, labs, or imaging studies that have been conducted or are required for the referral.
7. Mention any medications currently being taken by the patient.
8. Indicate whether the referral is urgent or routine and if an appointment needs to be scheduled.
9. Sign and date the referral form.
10. Keep a copy of the referral for your records.

Who needs specialty referral form 013014:

1. Patients who require specialized medical care beyond the scope of their primary care physician may need to fill out specialty referral form 013014.
2. Individuals who have been diagnosed with a specific medical condition or are experiencing symptoms that require the expertise of a specialist may also need this form.
3. Patients who have previously received a referral from their primary care physician and need to provide documentation to the specialist will need to fill out this form.

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What is specialty referral form 013014?

Specialty referral form 013014 is a document used to refer a patient to a specialist for further evaluation or treatment.

Who is required to file specialty referral form 013014?

Healthcare providers such as doctors, nurses, or other medical professionals are required to file specialty referral form 013014.

How to fill out specialty referral form 013014?

To fill out specialty referral form 013014, healthcare providers need to include patient information, reason for referral, and any relevant medical history.

What is the purpose of specialty referral form 013014?

The purpose of specialty referral form 013014 is to ensure that patients receive the necessary specialized care from a specialist.

What information must be reported on specialty referral form 013014?

Information such as patient demographics, reason for referral, current medications, and relevant medical history must be reported on specialty referral form 013014.