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CONCUSSION Physician Referral Dear Physician, It is suspected that has sustained a concussion on (NAME). He/she has been referred to you for further evaluation and/or clearance to be allowed (Date)

How to fill out concussion physician referral

How to Fill Out Concussion Physician Referral:

1. Obtain the referral form or document from the appropriate source. This may be provided by your primary care physician, a specialist, or your insurance provider.
2. Begin by filling out your personal information on the referral form. This typically includes your name, date of birth, address, and contact information.
3. Provide the name and contact information of the physician to whom you are being referred for concussion evaluation or treatment. This may be a neurologist, sports medicine specialist, or another healthcare professional experienced in managing concussions.
4. Indicate the reason for the referral. In this case, it would be for concussion evaluation or treatment. You may also need to provide details about the cause of the concussion, such as a sports-related injury or a fall.
5. If applicable, include information about any previous treatments or diagnostic tests you have undergone for the concussion. This can help the referring physician better understand your medical history and provide appropriate care.
6. If the referral form includes a section for additional comments or information, utilize it to provide any relevant details that you think the physician should know. This could include specific symptoms you are experiencing, concerns about your recovery progress, or any special circumstances related to your concussion.
7. Lastly, review the completed referral form for accuracy and ensure that all necessary information has been provided. If you have any doubts or questions, contact the referring physician's office for clarification.

Who Needs Concussion Physician Referral:

1. Individuals who have experienced a head injury with potential concussion symptoms should consider seeking a concussion physician referral.
2. Athletes who sustain head injuries during sports activities may be required to obtain a concussion physician referral before they can return to play.
3. Individuals who have persistent or worsening concussion symptoms, such as headaches, dizziness, memory problems, or difficulty concentrating, may need a referral to a specialist for further evaluation and management.
4. Patients who have already received initial medical care for a concussion but are not experiencing improvement or are encountering new symptoms may benefit from a referral to a concussion specialist.
5. Schools or organizations that have concussion management policies in place may require a physician referral for any student or athlete suspected of having a concussion, as part of their protocol for ensuring appropriate evaluation and treatment.

For pdfFiller’s FAQs

What is concussion physician referral?

Concussion physician referral is a form that is filled out by a healthcare provider to refer a patient who has suffered a concussion to a specialist for further evaluation and treatment.

Who is required to file concussion physician referral?

Healthcare providers who diagnose a patient with a concussion are required to file concussion physician referral.

How to fill out concussion physician referral?

Concussion physician referral is typically filled out with the patient's information, details of the concussion diagnosis, and the reason for the referral to a specialist.

What is the purpose of concussion physician referral?

The purpose of concussion physician referral is to ensure that patients who have suffered a concussion receive appropriate and timely care from a specialist.

What information must be reported on concussion physician referral?

The concussion physician referral form typically includes the patient's personal information, details of the concussion diagnosis, and the reason for the referral.

Where do I find concussion physician referral?

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