Get the free PATIENT REFERRAL REQUEST FORM Jonathon Faber DO David

PATIENT REFERRAL REQUEST FORM Jonathon Faber, DO, David Stadium, MD, Michael Via, MD, 536 S. Trimble Rd, Mansfield, OH 44906 Phone: (419) 7568899 FAX: (419) 5203561 Thank you for choosing OhioHealth

How to fill out patient referral request form

How to Fill Out a Patient Referral Request Form:

1. Start by gathering all necessary information: Before filling out the form, make sure you have all the required information at hand. This may include the patient's name, contact information, medical history, and reason for referral.
2. Provide the referring healthcare provider's details: In the designated section, enter the name, contact information, and any other necessary details of the referring healthcare provider. This can be a primary care physician, specialist, or any other healthcare professional initiating the referral.
3. Include the details of the referred healthcare provider: In this section, enter the name, contact information, and speciality of the healthcare provider to whom the patient is being referred. Make sure to double-check and provide accurate information.
4. Document the reason for referral: Clearly state the reason why the patient is being referred to another healthcare provider. This could be for a specific medical condition, diagnostic test, or a specialized treatment that the referring healthcare provider cannot provide.
5. Attach any supporting documents: If there are any relevant medical records, test results, or imaging reports that are necessary for the patient referral, make sure to attach copies of these documents to the referral form. This will help the referred healthcare provider have a better understanding of the patient's medical history and current condition.
6. Sign and date the form: Once you have filled out all the necessary information, sign and date the patient referral request form. This confirms that the information provided is accurate and that you agree to initiate the referral.

Who Needs a Patient Referral Request Form?

1. Patients seeking specialized care: Individuals who require specialized medical care that their primary healthcare provider cannot offer may need a patient referral request form. This could be for consultations with medical specialists, surgeries, or advanced diagnostic tests.
2. Primary care physicians: Primary care physicians often complete patient referral request forms on behalf of their patients. They may identify the need for specialized care and initiate the referral to ensure their patient receives appropriate treatment.
3. Specialists: In some cases, specialists themselves may initiate patient referral request forms for their patients. This occurs when the specialist believes that the patient would benefit from the expertise of another specialist or healthcare provider.

Remember, the requirements for patient referral request forms may vary depending on the healthcare system, the specific provider, and the nature of the referral. It is always important to follow the guidelines provided by the healthcare facility or insurance provider when filling out these forms.

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