Get the free Outpatient Consult Request Form - University of Michigan - medicine umich

For additonal information http //www. med.umich. edu/umconsults Physician Signature Requesting Signature Date. Outpatient Consult Request Form Department of Neurosurgery - Deep Brain Stimulation DBS Program Phone 734-936-7010 Fax 734-647-9233 Email mvt-disorders med.umich. Edu Referred to Deep Brain Stimulation DBS Program TO Dr. Kelvin Chou Medical Director Dr. Parag Patil Surgical Director Referring Physician FROM Office Name Contact Person Phone PCP if different from Referring Physician...

How to fill out outpatient consult request form

How to fill out outpatient consult request form

1. Step 1: Obtain the outpatient consult request form from the appropriate department or healthcare facility.
2. Step 2: Fill in your personal information such as your name, date of birth, gender, and contact details in the designated fields on the form.
3. Step 3: Provide information about your referring physician, including their name, contact information, and specialty.
4. Step 4: Specify the reason for the consultation and provide any relevant medical history or previous test results that may be necessary for evaluation.
5. Step 5: If there are any specific preferences or requirements for the consulting physician or department, mention them clearly on the form.
6. Step 6: Review the completed form for any errors or missing information. Make sure all sections are filled appropriately.
7. Step 7: Submit the filled-out outpatient consult request form to the concerned department or healthcare facility either in person or through the specified method (fax, email, etc.).
8. Step 8: Keep a copy of the submitted form for your records and follow up with the healthcare facility to ensure that your request has been received and processed.

Who needs outpatient consult request form?

1. Patients who require specialized evaluation or consultation for their medical condition.
2. Patients who need a referral from their primary care physician to see a specialist or receive a second opinion.
3. Hospitals, clinics, or healthcare facilities that require a standardized form for documenting and processing outpatient consult requests.
4. Healthcare professionals who need to refer their patients to specialists or other departments for further assessment or care.

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What is outpatient consult request form?

Outpatient consult request form is a document used to request a consultation from a specialist for a patient receiving outpatient care.

Who is required to file outpatient consult request form?

The attending physician or healthcare provider is required to file the outpatient consult request form.

How to fill out outpatient consult request form?

To fill out the outpatient consult request form, the attending physician must provide patient information, reason for consultation, requested specialist, and any relevant medical history.

What is the purpose of outpatient consult request form?

The purpose of outpatient consult request form is to facilitate communication between healthcare providers and ensure that patients receive appropriate specialist consultation.

What information must be reported on outpatient consult request form?

The outpatient consult request form must include patient demographics, reason for consultation, relevant medical history, and requested specialist.