Get the free Physician Referral/Clearance Form

This form is used to obtain a physician's or therapist's approval for patients wishing to begin exercising or participating in sports at the Cleveland Clinic Employee Health and Wellness Center based

How to fill out physician referralclearance form

How to fill out Physician Referral/Clearance Form

1. Begin with the patient's personal information, including name, date of birth, and contact details.
2. Provide the referring physician's details, including their name, contact information, and any relevant credentials.
3. Clearly state the medical reason for the referral, including symptoms or conditions that need evaluation.
4. Include any necessary medical history related to the patient's condition, highlighting previous treatments or medications.
5. Specify any required tests or evaluations that should be conducted by the referred physician.
6. Sign and date the form as the referring physician, ensuring all required details are completed.
7. Make a copy for your records and provide the patient with the original to take to the referred physician.

Who needs Physician Referral/Clearance Form?

1. Patients who need specialized care or evaluation from a different physician or specialist.
2. Individuals requiring medical clearance for sports or other physical activities.
3. Patients needing referrals for specific tests or procedures not offered by their primary care physician.
4. Anyone enrolled in a health insurance plan that mandates referrals for specialist visits.

For pdfFiller’s FAQs

What is Physician Referral/Clearance Form?

The Physician Referral/Clearance Form is a document used in healthcare settings to obtain a referral or clearance from a physician before a patient can proceed with certain treatments, procedures, or specialized care.

Who is required to file Physician Referral/Clearance Form?

Typically, patients seeking specialist care or certain medical services are required to file Physician Referral/Clearance Forms. Additionally, healthcare providers may also be responsible for submitting these forms on behalf of the patients.

How to fill out Physician Referral/Clearance Form?

To fill out the Physician Referral/Clearance Form, provide the patient's personal information, reason for referral, details of the referring physician, and any specific medical history or conditions relevant to the referral.

What is the purpose of Physician Referral/Clearance Form?

The purpose of the Physician Referral/Clearance Form is to ensure that patients receive the necessary medical evaluations and treatments from the appropriate specialists, while also ensuring continuity of care and communication between healthcare providers.

What information must be reported on Physician Referral/Clearance Form?

The information that must be reported includes patient demographics (name, age, contact information), medical history, reasons for referral, referring physician's details, and any other pertinent health information that may assist the specialist.