Get the free Patient Referral Form - Sutter Pacific Medical Foundation

Patient Referral Form 4156000770 4156000775 (fax) 866663KIDS (5437) Cardiology Marina Beer, M.D., FLAP Ellen Chan, M.D. Nikola Tide, M.D., FLAP Andrea LeavyButler, PNP Endocrinology Such Bhatia, M.D.

How to fill out patient referral form

1. Start by obtaining a patient referral form from the healthcare provider or facility. This form may be available online or can be obtained in person from the reception or registration desk.
2. Before filling out the form, gather all the necessary information. This includes the patient's full name, date of birth, address, contact number, and any relevant medical history. You may also need the name and contact information of the referring healthcare provider.
3. Begin by filling in the patient's personal information section. Write the full name, including any middle names or initials, in the designated space. Enter the date of birth in the proper format and provide the patient's current residential address.
4. Move on to the contact information section. Fill in the patient's primary phone number, secondary phone number (if applicable), and an email address. If the patient does not have an email address, this can be left blank.
5. Some referral forms may require the patient to provide their insurance information. If this is the case, have the patient's insurance card on hand and fill in the details accurately. This may include the insurance company's name, policy number, group number, and any other relevant information.
6. Look for a section on the form that asks for the primary reason for the referral. Provide a concise and clear description of why the patient needs to be referred to another healthcare specialist or facility. This section may also require additional details such as the area of concern or any specific tests or treatments required.
7. If the patient has any relevant medical history, allergies, or current medications, look for a section on the form that addresses this. Fill in the appropriate details, including the name of the medication, dosage, and frequency if applicable.
8. In some cases, the referring healthcare provider's information may be required. This can include their full name, the name of their practice or organization, contact number, and any other necessary details. Ensure that this information is accurate before submitting the referral form.

Who needs a patient referral form:

1. Patients who require specialized medical care beyond the expertise of their primary healthcare provider.
2. Patients who need to see a specialist for a specific medical condition or expertise.
3. Patients who are seeking a second opinion or consultation from another healthcare professional.
4. Patients who need to continue ongoing care with a different healthcare facility or provider.
5. Patients who are participating in a coordinated care program or managed care system that requires referrals.

Remember, the specific requirements for a patient referral form may vary depending on the healthcare provider, facility, or insurance company involved. It's important to carefully read and follow the instructions provided on the form to ensure accurate and efficient processing.

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What is patient referral form?

The patient referral form is a document used by healthcare providers to recommend a patient to another provider or specialist for further evaluation or treatment.

Who is required to file patient referral form?

Healthcare providers such as doctors, nurses, and specialists are required to file patient referral forms when referring a patient to another provider.

How to fill out patient referral form?

Patient referral forms can typically be filled out electronically or on paper, and include information about the referring provider, the patient's information, and the reason for the referral.

What is the purpose of patient referral form?

The purpose of the patient referral form is to ensure proper communication and continuity of care between healthcare providers, as well as to facilitate the transfer of medical information.

What information must be reported on patient referral form?

Patient referral forms typically require the patient's name, contact information, medical history, reason for referral, and any relevant test results or medications.