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The Mark H. Bandmaster Center 3100 Plaza Properties Blvd. Columbus, OH 43219 Phone: 6143836475 Fax: 614.383.6155 Fax Referral Form Referring Physician Information Referring Physicians Name: Referring

How to fill out referral form

How to fill out a referral form:

1. Start by obtaining a referral form from the appropriate source, such as a healthcare provider, employer, or organization.
2. Carefully read the instructions provided on the referral form as they may vary depending on the purpose of the referral.
3. Fill in your personal information accurately and completely. This may include your full name, contact information, date of birth, address, and any relevant identification numbers.
4. Provide detailed information about the person or organization being referred. Include their name, contact information, and any relevant background or history that may be required.
5. Clearly state the reason for the referral, specifying the type of service or assistance needed.
6. If applicable, provide any supporting documents or medical records that may be required. This could include medical reports, test results, or other relevant documentation.
7. Ensure that you have signed and dated the referral form, as this is often a required step.
8. Review the completed form for accuracy and completeness before submitting it to the designated recipient.
9. Keep a copy of the filled referral form for your own records.

Who needs a referral form:

1. Patients seeking specialized medical care often require a referral form from their primary healthcare provider to access services from a specialist.
2. Individuals who are participating in employee assistance programs or insurance plans may need a referral form from their employer or insurance company to access certain services.
3. Students who wish to receive counseling or other support services within an educational institution may be required to obtain a referral form from a teacher, counselor, or administrator.
4. Organizations or agencies that offer assistance programs or services may require individuals to have a referral form from an authorized referring party before they can access their offerings.
5. Referral forms are also commonly used in legal, social, and community service settings to refer individuals to appropriate resources or professionals based on their needs.

Note: The specific need for a referral form can vary depending on the context and the requirements set forth by the organization or institution requesting the referral. It's important to follow the guidelines and procedures outlined by the issuing party when filling out and submitting a referral form.

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