Get the free outpatient psychiatric referral request

BROCKVILLEGENERALHOSPITAL OUTPATIENT PSYCHIATRICREFERRALREQUESTAsofNovember2022PLEASERETURNTOBGHINTAKEFAX6133426020REFERRAL INFORMATION DateofReferral(YYY/MM/DD):___ ReferringPhysician/ReferringSource:___ TelephoneNumber:___Number:___ PhysicianBillingNumber:___ PhysicianSignature: PATIENTINFORMATION IdentificationofFirstLanguage:EnglishFrenchOther:___Name

How to fill out outpatient psychiatric referral request

How to fill out outpatient psychiatric referral request

1. Obtain a referral form from the patient's primary care provider or insurance company.
2. Fill out the patient's demographic information including name, date of birth, address, and insurance information.
3. Provide a brief summary of the patient's mental health history and current symptoms.
4. Include any relevant medical records or test results that may support the referral.
5. Specify the reason for the referral and the type of services requested (e.g. diagnostic evaluation, medication management, therapy, etc.).
6. Obtain any necessary prior authorizations or approvals before submitting the referral.
7. Submit the completed referral form to the designated outpatient psychiatric clinic or provider.

Who needs outpatient psychiatric referral request?

1. Patients who require ongoing mental health treatment and therapy.
2. Primary care providers who believe their patients would benefit from psychiatric evaluation and treatment.
3. Insurance companies or managed care organizations who require referrals for mental health services.

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What is outpatient psychiatric referral request?

Outpatient psychiatric referral request is a form filled out by a healthcare provider to refer a patient to a psychiatric service for outpatient care.

Who is required to file outpatient psychiatric referral request?

Healthcare providers such as physicians, psychologists, and social workers are required to file outpatient psychiatric referral requests.

How to fill out outpatient psychiatric referral request?

Outpatient psychiatric referral requests can be filled out by providing the patient's information, reason for referral, and any relevant medical history.

What is the purpose of outpatient psychiatric referral request?

The purpose of outpatient psychiatric referral request is to ensure that patients receive the appropriate psychiatric care they need in an outpatient setting.

What information must be reported on outpatient psychiatric referral request?

Information such as patient's demographics, reason for referral, current symptoms, relevant medical history, and referring provider's contact information must be reported on the outpatient psychiatric referral request.