CA Good Samaritan Hospital Patient Referral free printable template

Authorization obtained by Affusion Staff Initials: Date: Ambulatory Infusion Center Patient Referral and Prescription for Blood Transfusion Return Signed RX via Fax to 1-888-310-0856 To: Tina Benkendorfer,

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How to fill out CA Good Samaritan Hospital Patient Referral and

1. Obtain the CA Good Samaritan Hospital Patient Referral form from the hospital's website or administration office.
2. Fill out the patient's personal information, including name, date of birth, and contact details.
3. Provide the referring physician's information, including name, clinic, and contact number.
4. Select the reason for referral from the options available on the form.
5. Include any relevant medical history or notes that may assist in the patient's care.
6. Sign and date the referral form to confirm its accuracy.
7. Submit the completed referral form to the hospital via email, fax, or in-person delivery.

Who needs CA Good Samaritan Hospital Patient Referral and?

1. Patients who require specialized medical services not provided by their primary healthcare provider.
2. Physicians needing to refer their patients to the hospital for advanced diagnostic or treatment options.
3. Patient who require admission for urgent or emergency care at CA Good Samaritan Hospital.
4. Patients needing continuity of care after receiving treatment from a specialist.

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What is CA Good Samaritan Hospital Patient Referral and?

CA Good Samaritan Hospital Patient Referral is a process for referring patients to specialized medical services, ensuring they receive appropriate care based on their medical needs.

Who is required to file CA Good Samaritan Hospital Patient Referral and?

Healthcare providers, including physicians and other authorized personnel involved in the patient's care, are required to file the CA Good Samaritan Hospital Patient Referral.

How to fill out CA Good Samaritan Hospital Patient Referral and?

To fill out the CA Good Samaritan Hospital Patient Referral, one must complete the referral form by providing patient details, the referring physician's information, the requested services, and justification for the referral.

What is the purpose of CA Good Samaritan Hospital Patient Referral and?

The purpose of the CA Good Samaritan Hospital Patient Referral is to facilitate timely and efficient access to necessary medical services, ensuring patients receive the right care at the right time.

What information must be reported on CA Good Samaritan Hospital Patient Referral and?

The information that must be reported includes the patient's name, date of birth, insurance details, diagnosis or medical condition, referring physician's details, and the specific services being requested.