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Physician Referral Form For adults (at least 19 years of age) experiencing mild to moderate depression (PHQ-9 range 5 to 19), with or without anxiety, community coaches provide telephone delivery

How to fill out physician referral form

How to fill out a physician referral form:

1. Start by carefully reading the instructions on the form. Make sure you understand all the requirements and information being requested.
2. Begin by filling out your personal information, such as your name, address, phone number, and date of birth. Provide accurate and up-to-date details.
3. Next, provide information about your primary care physician or referring doctor. This may include their name, contact information, and any special instructions they have given regarding the referral.
4. Fill in the details about your medical condition or reason for seeking a specialist. Be as specific as possible, mentioning any relevant symptoms, tests, or medical history that might assist the specialist.
5. If you have chosen a specific specialist or healthcare provider, include their name, address, and any other required details. If you're unsure of who to choose, seek guidance from your primary care physician.
6. Make sure to include the date you would like to schedule the appointment or any preferred time frame for the referral.
7. If necessary, securely attach any supporting documents, such as medical reports, test results, or previous consultation records, that may be required by the specialist or healthcare provider.
8. Review the completed form, ensuring all information is accurate and legible. Double-check for any missing or incomplete fields.
9. Once you are confident that the form is filled out correctly, submit it according to the instructions provided. This may involve mailing the form, handing it directly to your primary care physician's office, or submitting it online depending on the healthcare system's procedures.

Who needs a physician referral form?

1. Patients who have been evaluated by their primary care physician and are being referred to a specialist or a different healthcare provider.
2. Individuals seeking specialized medical care or diagnostic tests that require a referral from their primary care physician or insurance provider.
3. Patients whose insurance provider or healthcare system requires a referral in order to receive coverage for specialist consultations or procedures.

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