Get the free Ambulatory Services Referral Form Please complete, print and

Ambulatory Services Referral Form Please complete, print and fax to 5135842599. Thank you for your referral to UC health Ambulatory Services. Referrals to UC Health can be made by completing the form

How to fill out ambulatory services referral form

How to fill out ambulatory services referral form

1. Start by obtaining an ambulatory services referral form from the appropriate source, such as a medical practitioner or healthcare facility.
2. Read and understand the instructions given on the referral form.
3. Fill in your personal information accurately, including your name, date of birth, contact details, and any applicable identification numbers.
4. Provide information about your referring medical practitioner or healthcare provider, including their name, contact information, and any relevant identification numbers.
5. Specify the reason for the referral and provide any necessary details or supporting documentation.
6. Provide information about the ambulatory services you are being referred for, including any specific tests, treatments, or procedures.
7. If applicable, indicate any preferences or special requirements you may have regarding the ambulatory services.
8. Review the filled-out referral form to ensure all information is accurate and complete.
9. Submit the completed referral form to the designated recipient, such as the ambulatory services department or healthcare provider.
10. Keep a copy of the filled-out referral form for your records.

Who needs ambulatory services referral form?

1. Individuals who require ambulatory services, which are medical services that can be provided on an outpatient basis, may need to fill out an ambulatory services referral form.
2. This form is typically required by healthcare providers or medical practitioners who are referring a patient for specific ambulatory services, such as diagnostic tests, consultations, therapies, or minor surgeries.
3. Both adult and pediatric patients may need to fill out this form, depending on their healthcare needs and the requirements of the ambulatory services provider.
4. It is important to consult with your healthcare provider or medical practitioner to determine if you need to fill out an ambulatory services referral form for your specific situation.

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