Get the free Fetal Therapy referral form - hopkinsmedicine

PLEASE FAX REFERRAL FORM TO: (626) 3563379. Insurance authorization will be coordinated by Allyn Planes, RN/Kris Rally, RN, who may be contacted by phone at. (626)3563360, or by email at Allyn. Planes

How to fill out fetal therapy referral form

How to fill out a fetal therapy referral form:

1. Gather all necessary information: Before beginning to fill out the referral form, it is important to collect all relevant information. This may include the patient's personal details, medical history, diagnostic test results, and any other relevant information.
2. Complete the patient's information: Start by filling out the patient's personal details, such as their full name, date of birth, gender, contact information, and insurance details. Ensure that all information is accurate and up-to-date.
3. Provide the referring healthcare provider's details: In this section, include the name, contact information, and speciality of the healthcare provider who is referring the patient for fetal therapy. This could be an obstetrician, perinatologist, or other relevant specialist.
4. Indicate the reason for referral: Specify the reason why the patient is being referred for fetal therapy. This could be due to a fetal anomaly, high-risk pregnancy, genetic condition, or any other relevant indication. Provide a clear and concise description of the reason for referral.
5. Include relevant medical history: Document any relevant medical history of the patient that may impact the fetal therapy. This may include previous pregnancies, medical conditions, medications, allergies, or surgeries. Ensure that all details are accurate and comprehensive.
6. Attach supporting documentation: If available, attach any supporting documents or diagnostic test results that provide further information about the patient's condition and the need for fetal therapy. This may include ultrasound reports, genetic test results, or other pertinent medical records.

Who needs a fetal therapy referral form?

1. Patients with high-risk pregnancies: Fetal therapy referral forms may be required for pregnant women who are deemed to have high-risk pregnancies. This could be due to a variety of factors, such as fetal anomalies, genetic conditions, or maternal health concerns.
2. Obstetricians and perinatologists: Healthcare providers specializing in obstetrics and perinatology often use fetal therapy referral forms to refer their patients to specialized fetal therapy centers. These professionals collaborate with fetal therapy specialists to ensure the best possible care for high-risk pregnancies.
3. Genetic counselors and genetic specialists: Patients who require genetic counseling or those with a known genetic condition may also need a fetal therapy referral form. Genetic specialists may refer these patients for fetal therapy services, such as genetic testing or counseling, to aid in making informed decisions about their pregnancy.

In conclusion, filling out a fetal therapy referral form involves gathering necessary information, completing patient and referring healthcare provider details, specifying the reason for referral, providing relevant medical history, and attaching supporting documentation. Fetal therapy referral forms are typically needed for patients with high-risk pregnancies, and they are commonly used by obstetricians, perinatologists, and genetic specialists.

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What is fetal therapy referral form?

The fetal therapy referral form is a document used to refer a pregnant woman to specialized medical care for the treatment of fetal abnormalities or disorders.

Who is required to file fetal therapy referral form?

The form is typically filled out by the obstetrician or healthcare provider overseeing the pregnancy.

How to fill out fetal therapy referral form?

To fill out the form, the healthcare provider must provide detailed information about the pregnancy, any fetal abnormalities detected, and the reason for the referral.

What is the purpose of fetal therapy referral form?

The purpose of the form is to ensure that pregnant women with fetal abnormalities receive timely and appropriate medical care to support the health of both the mother and the fetus.

What information must be reported on fetal therapy referral form?

The form typically requires information about the pregnant woman's medical history, results of prenatal testing, details of any fetal abnormalities detected, and the recommended course of treatment.