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301 N. Madison St. 3d Floor, Suite 310 Joliet, IL 60345 815.773.7737 phone 815.773.7761 fax -Express Referral Worcester for Wound and Hyperbaric Medicine PLEASE RETURN COMPLETED FORM VIA FAX Date:
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How to fill out express referral form- center
How to fill out express referral form- center:
01
Start by gathering all the necessary information. This includes the patient's personal details such as their full name, date of birth, address, and contact information. It is also important to have their insurance information, including the policy and group numbers.
02
Once you have all the required information, begin filling out the patient's medical history. This may include past illnesses or conditions, previous surgeries, allergies, and any ongoing medications. Fill in this section accurately to ensure proper medical care and avoid any potential complications.
03
Next, provide reasons for the referral. Clearly state the symptoms or concerns that led to the need for the referral. Include any relevant test results or medical reports that support the need for further evaluation or treatment.
04
Provide the details of the healthcare professional or specialist to whom you are referring the patient. Include their name, title, address, and contact information. It is important to double-check that all the information is correct and up to date.
05
If there are any specific instructions or preferences for the referral, make sure to note them in the form. For example, if you believe a certain type of specialist or specific tests are required, mention it clearly in this section.
06
Lastly, review the form for accuracy and completeness. Ensure that all the required fields are filled out, and there are no spelling or grammatical errors. Double-check that you have included all the necessary supporting documents, such as medical reports or test results.
Who needs express referral form- center:
01
Patients who require specialized medical care beyond the expertise of the primary care provider.
02
Individuals who need a second opinion or evaluation from a specialist.
03
Patients whose condition necessitates further tests, treatments, or procedures that cannot be provided by the primary care provider alone.
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