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Indiana Tobacco QuitlinePatient ID×CLINIC FAX REFERRAL FORM FAX 1.800.483.3114 Indiana's Tobacco QuitlineClinicDate Fax Sent / / PROVIDER INFORMATION Clinic Name Health Care Provider Address City
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How to fill out clinic fax referral form
How to fill out clinic fax referral form
01
Read the instructions on the clinic fax referral form.
02
Gather all the necessary information required to fill out the form, like patient's personal details, healthcare provider information, and reason for referral.
03
Ensure you have the appropriate medical documentation to support the referral.
04
Fill out the patient's personal information accurately, including their full name, date of birth, contact details, and health insurance information.
05
Provide the healthcare provider's details, including their name, clinic or hospital name, contact information, and any relevant identification or referral numbers.
06
Specify the reason for the referral, providing clear and concise details about the patient's condition or symptoms.
07
Write down any specific requirements or instructions for the referral, if applicable.
08
Review the completed form for any errors or missing information.
09
Submit the clinic fax referral form to the intended recipient through the appropriate fax number or method specified.
10
Keep a copy of the filled-out form for your records.
Who needs clinic fax referral form?
01
Patients who require a referral from a primary care physician to a specialist.
02
Healthcare providers or clinics who need to refer a patient to another healthcare professional or facility.
03
Individuals seeking specialized medical care or second opinions.
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