Get the free 17P Alere Referral form - Indiana Perinatal Network

Physician NPI: Practice Zip Code: Alar Referral To: Referral Team Physician Name: Fax: 317-842-2684 OR 317-842-2694 Practice Fax: Phone: Practice Phone: 800-999-2415 Date: Office Contact: Patient

How to fill out 17p alere referral form

How to fill out 17p alere referral form:

1. Start by carefully reading the instructions provided on the form. This will give you a clear understanding of the information you need to provide and any specific guidelines to follow.
2. Begin filling out the form by entering your personal details, such as your name, address, and contact information. Make sure to double-check the accuracy of your information before moving on to the next section.
3. The next step is to provide the relevant medical information. This may include your medical history, any current medications you are taking, and any previous diagnoses or treatments related to the condition for which the referral is required.
4. If the referral form requires information from your healthcare provider, ensure that you have the necessary details on hand, such as their name, address, and contact information. You may also need to provide details about the specific healthcare professional or facility to which you are being referred.
5. Some referral forms may have additional sections or questions that need to be answered. Take your time to carefully review each section and provide the required information accurately.
6. Once you have completed filling out the form, review it one more time to ensure that all the information provided is correct and legible. Any errors or missing information could result in delays or complications in the referral process.
7. Finally, sign and date the form as required. This serves as your consent and acknowledgment of the information provided.

Who needs 17p alere referral form:

1. Pregnant individuals meeting certain risk criteria may need to fill out the 17p alere referral form. The form is typically used to initiate the referral process for 17p administration, a treatment aimed at reducing the risk of preterm birth.
2. Healthcare providers, such as obstetricians or midwives, may require their patients who meet the criteria to fill out the referral form.
3. The form is generally used in healthcare settings where 17p administration is available as a preventive measure for preterm birth. Individuals seeking this specific treatment may need to complete the form to initiate the referral process.

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