Get the free health.ucdavis.eduTelehealthReferralFormReferral Request Form - University of Califo...

Physician to Complete Date of Referral: Patient Name: DOB: Patients Home Phone Number: Alternate Number: Address: Referring MD: Referring MD Phone Number: Referring MD Office Fax Number: PLEASE ATTACH

How to fill out healthucdavisedutelehealthreferralformreferral request form

How to fill out healthucdavisedutelehealthreferralformreferral request form

1. To fill out the healthucdavisedutelehealthreferralformreferral request form, follow these steps:
2. Start by downloading the referral form from the healthucdavisedu website.
3. Open the downloaded form using a PDF reader on your computer.
4. Fill in the patient's personal information, including their name, contact details, and date of birth.
5. Provide the referring provider's information, such as their name, contact details, and medical license number.
6. Specify the reason for the referral and any relevant medical history of the patient.
7. Include any additional documents or test results that support the need for the referral.
8. Review the completed form to ensure all the information is accurate and up-to-date.
9. Save the filled-out form as a PDF file.
10. Send the completed referral form to the designated recipient, either via email or by faxing it to the appropriate fax number.
11. Keep a copy of the filled-out form for your records.

Who needs healthucdavisedutelehealthreferralformreferral request form?

1. Any patient who requires a telehealth referral from the healthucdavisedu healthcare system needs to fill out the healthucdavisedutelehealthreferralformreferral request form.
2. This form is necessary for patients who need specialized medical services or consultations through telehealth and wish to connect with providers at healthucdavisedu remotely.
3. It helps in the process of referring patients to the appropriate healthcare professionals within healthucdavisedu's telehealth system.

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What is healthucdavisedutelehealthreferralformreferral request form?

The healthucdavisedutelehealthreferralform is a form used to request a referral for telehealth services at UC Davis Health.

Who is required to file healthucdavisedutelehealthreferralformreferral request form?

Patients or healthcare providers who are seeking telehealth services at UC Davis Health are required to fill out the referral request form.

How to fill out healthucdavisedutelehealthreferralformreferral request form?

The form can be filled out online on the UC Davis Health website or by contacting the telehealth department directly for assistance.

What is the purpose of healthucdavisedutelehealthreferralformreferral request form?

The purpose of the form is to facilitate the referral process for patients and healthcare providers who are interested in telehealth services at UC Davis Health.

What information must be reported on healthucdavisedutelehealthreferralformreferral request form?

The form typically requires information such as patient's name, contact details, reason for referral, medical history, and insurance information.