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REFERRAL / INTAKE FORM Patient Name: SS / Medicare #: Address: Medicaid # INS (PVT) Workers Comp: City / State / Zip: INS (PVT) Worker Comp: * Attach Verification Sheet Phone #s D.O.B.: Referral Source:
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How to fill out referral bintakeb form
How to Fill Out a Referral Intake Form:
01
Start by entering your personal information, such as your name, contact details, and any relevant identification numbers.
02
Provide background information about why you are seeking a referral, including your current situation, concerns, and any previous treatments or medications.
03
Indicate the specific referral you are requesting, whether it is for a specialist, a therapy program, or another type of service.
04
Provide any additional details or notes that could help the person reviewing the form to understand your needs better.
05
Check for any required attachments or documents that need to be included with the form, such as medical records or test results.
06
Review the completed form to ensure all the necessary information is included and legible.
07
Sign and date the form to validate your submission.
08
Submit the form according to the provided instructions, whether it is through mail, fax, or an online portal.
Who Needs a Referral Intake Form?
01
Individuals seeking specialized medical care or treatment may need to fill out a referral intake form to initiate the referral process.
02
Patients who require therapy services, such as physical therapy, occupational therapy, or speech therapy, may also be required to complete a referral intake form.
03
Individuals looking to access specific programs or services, such as mental health counseling or substance abuse treatment, might need to fill out a referral intake form as well.
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