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OUTPATIENT CONSULT REQUEST Division of NephrologySend Form and Records to: IntMedNephCallCenter@med.umich.edu Or Fax to: 73499825161500 East Medical Center Drive Ann Arbor, MI 481090361 Office: 8882871084

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How to fill out outpatient consult request

01

Obtain outpatient consult request form from the hospital or clinic

02

Fill out patient's demographic details like name, age, gender, and contact information

03

Provide relevant medical history and reason for the consultation

04

Specify the specialty or department you are requesting the consultation from

05

Include any relevant test results or imaging reports

06

Sign and date the request form before submitting it to the appropriate department

Who needs outpatient consult request?

01

Patients who require specialized medical opinion or treatment from a different healthcare provider

02

Healthcare providers seeking expert advice or consultation for their patients

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What is outpatient consult request?

An outpatient consult request is a formal request made by a healthcare provider for a patient to receive consultation or care from another healthcare provider outside of a hospital setting.

Who is required to file outpatient consult request?

Any healthcare provider who believes that a patient would benefit from consultation or care from another healthcare provider.

How to fill out outpatient consult request?

The outpatient consult request form must be completed with all relevant patient information, reason for consultation, and any other pertinent details before submitting it to the desired healthcare provider.

What is the purpose of outpatient consult request?

The purpose of an outpatient consult request is to facilitate communication and collaboration between healthcare providers in order to provide the best possible care for the patient.

What information must be reported on outpatient consult request?

The outpatient consult request must include patient demographics, reason for consultation, relevant medical history, current medications, and any other relevant information.

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