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PROVIDER REFERRAL CHECKLISTChilds Name : D.O.B.: PSC: Referral Date: Provider Name:Consultants: Complete ISP H.E.L.P. Strands Booklet (Do not need to send to IMPACT) Demographic Page Early Steps Release
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The provider referral checklist is a document used to facilitate and track referrals between healthcare providers.
Healthcare providers involved in making or receiving patient referrals are required to file the provider referral checklist.
The provider referral checklist can be filled out by documenting the patient's information, reason for referral, referring provider's information, and receiving provider's information.
The purpose of the provider referral checklist is to ensure smooth and efficient communication and coordination between healthcare providers during patient referrals.
The provider referral checklist must include patient demographics, reason for referral, referring provider details, receiving provider details, and any relevant medical history.
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