Get the free CARE Clinic Referral Form - Phoenix Children's Hospital

CARE Clinic Referral Sheet (PC Use Only Pt Label) Division of Endocrinology and Diabetes P: 6029330935 F: 6029332471 MAN Referring Provider Information Date: Referring Provider: Phone: Fax: Medical

How to fill out care clinic referral form

How to fill out care clinic referral form

1. Start by printing out the care clinic referral form.
2. Fill out your personal information accurately, including your name, address, and contact number.
3. Provide details about your current health condition and any relevant medical history.
4. Specify the reason for seeking care at the clinic and the type of specialist required if known.
5. If you have any medications or allergies, mention them in the appropriate section.
6. If you have medical insurance, provide the necessary details for billing purposes.
7. Review the completed form for any errors or missing information.
8. Sign and date the referral form before submitting it to the care clinic.

Who needs care clinic referral form?

1. Anyone who requires specialized medical care at a care clinic may need to fill out a referral form.
2. Patients seeking consultation with a specialist, such as a dermatologist, cardiologist, or orthopedic surgeon, usually need a care clinic referral form.
3. Individuals who have been referred by their primary care physician or another healthcare provider also require a care clinic referral form.
4. If you have a specific medical condition or need a specialized treatment that cannot be provided by your regular doctor, you may need to fill out a care clinic referral form.

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What is care clinic referral form?

The care clinic referral form is a document used to refer patients to a specialized clinic or healthcare facility for further treatment or consultation.

Who is required to file care clinic referral form?

Healthcare providers such as doctors, nurses, or social workers are required to file the care clinic referral form.

How to fill out care clinic referral form?

The care clinic referral form can be filled out by providing patient information, medical history, reason for referral, and contact information of both the referring healthcare provider and the receiving clinic.

What is the purpose of care clinic referral form?

The purpose of the care clinic referral form is to ensure a smooth transfer of patients from one healthcare provider to another for specialized care or treatment.

What information must be reported on care clinic referral form?

The care clinic referral form must include patient demographics, medical history, reason for referral, current medications, allergies, and contact information of the referring and receiving healthcare providers.