Get the free CROHN'S REFERRAL FORM - Prime Therapeutics

SIGN AND FAX THIS FORM TO 877.828.3939 If you have questions, please call 877.627.MEDS (6337) PATIENT/PRESCRIBE RE R KATIE N T/P R ES CR I B CROHN S REFERRAL FORM PATIENT INFORMATION PRESCRIBER INFORMATION

How to fill out crohn39s referral form

How to fill out Crohn's referral form:

1. Contact your primary care physician (PCP): Start by discussing your symptoms and concerns with your PCP. They will evaluate your condition and determine if a referral to a specialist, such as a gastroenterologist, is necessary.
2. Obtain the referral form: If your PCP decides that a referral is appropriate, they will provide you with the Crohn's referral form. This form may be a physical document or an electronic form, depending on your healthcare provider's procedures.
3. Fill in your personal information: The referral form will require you to provide your full name, contact details, date of birth, and insurance information. Ensure that this information is accurate and up to date.
4. Describe your symptoms: The referral form will include sections to describe your symptoms and any related medical history. Be as detailed as possible, providing information about the duration and intensity of your symptoms, any changes in bowel habits, abdominal pain, weight loss, or other relevant factors.
5. Indicate the need for a specialist: Clearly express your need to see a gastroenterologist or specialist familiar with Crohn's disease. Describe why you believe a specialist's evaluation is necessary and how it can potentially benefit your healthcare.
6. Attach supporting documents (if required): Some referral forms may ask for additional documentation, such as laboratory test results, imaging scans, or previous medical records. If requested, make sure to gather these documents and attach them to the referral form before submitting it.

Who needs Crohn's referral form?

1. Patients with suspected Crohn's disease: Individuals who exhibit symptoms suggestive of Crohn's disease, such as chronic diarrhea, abdominal pain, fatigue, rectal bleeding, weight loss, or a family history of inflammatory bowel disease, may require a referral form.
2. Individuals seeking specialized care: Even if you have already been diagnosed with Crohn's disease, you may still need a referral form to see a gastroenterologist or another healthcare professional specializing in the management and treatment of Crohn's disease.
3. Patients requiring a second opinion: If you want a second opinion from a different doctor or healthcare facility, you may need a referral form to request the evaluation of a specialist outside your current healthcare network.

Remember, healthcare practices and referral processes may differ, so it's important to follow your healthcare provider's specific instructions on filling out the Crohn's referral form and obtaining the necessary approvals for specialist care.

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