HI Hawaii Specialty Pharmacy Gastroenterology Referral Form 2017 free printable template

GASTROENTEROLOGY REFERRAL FORM Please complete and attach to MDX prior Authorization formation INFORMATION: Patient Name: Address: City: State: Zip: Home Phone: Alternate Phone: Email: Soc. Sec #:

How to fill out HI Hawaii Specialty Pharmacy Gastroenterology Referral

How to fill out HI Hawaii Specialty Pharmacy Gastroenterology Referral Form

1. Obtain the HI Hawaii Specialty Pharmacy Gastroenterology Referral Form from the official website or your healthcare provider.
2. Fill out the patient's personal information including name, date of birth, and contact details.
3. Provide the referring physician's information, including name, contact number, and practice address.
4. Indicate the pertinent medical history of the patient that relates to gastrointestinal conditions.
5. List any current medications the patient is taking.
6. Include specific reasons for the referral and any relevant test results.
7. Sign and date the form as the referring physician.
8. Submit the completed form to HI Hawaii Specialty Pharmacy via fax or email.

Who needs HI Hawaii Specialty Pharmacy Gastroenterology Referral Form?

1. Patients experiencing gastrointestinal issues that require specialized care.
2. Primary care physicians looking to refer patients to a gastroenterologist.
3. Healthcare providers validating the need for specialized gastroenterology services.

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What is HI Hawaii Specialty Pharmacy Gastroenterology Referral Form?

The HI Hawaii Specialty Pharmacy Gastroenterology Referral Form is a document used to refer patients for specialized gastroenterology services and treatments provided by Hawaii Specialty Pharmacy.

Who is required to file HI Hawaii Specialty Pharmacy Gastroenterology Referral Form?

Typically, healthcare providers, such as primary care physicians or other specialists, are required to file the HI Hawaii Specialty Pharmacy Gastroenterology Referral Form to initiate the referral process for their patients.

How to fill out HI Hawaii Specialty Pharmacy Gastroenterology Referral Form?

To fill out the HI Hawaii Specialty Pharmacy Gastroenterology Referral Form, healthcare providers must provide patient information, details of the referral reason, any relevant medical history, and contact information for both the referring provider and the patient.

What is the purpose of HI Hawaii Specialty Pharmacy Gastroenterology Referral Form?

The purpose of the HI Hawaii Specialty Pharmacy Gastroenterology Referral Form is to facilitate the referral process for patients requiring specialized gastroenterology care, ensuring proper communication between referring and specialty providers.

What information must be reported on HI Hawaii Specialty Pharmacy Gastroenterology Referral Form?

The information that must be reported on the HI Hawaii Specialty Pharmacy Gastroenterology Referral Form includes patient demographics, medical history, the reason for referral, medications, and the referring physician's contact information.