Get the free Hearing Screening Referral and Physician Report bFormb - scschools
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3192 Turnpike St., Susquehanna, PA 18847 Phone (570) 8534921 Elementary School Health Office Ext. 1345 or 1343 Fax: (570) 8533092 www.scschools.org High School Health Office Ext. 2347 Fax: (570) 8533918
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How to fill out hearing screening referral and
When filling out a hearing screening referral, it is important to follow these steps:
01
Start by gathering all the necessary information. This includes the patient's personal details such as their name, date of birth, address, and contact information. Additionally, have their medical history, including any previous hearing tests or related diagnoses.
02
Next, fill in the reason for the referral. Specify why the patient needs a hearing screening and provide any additional relevant details or concerns. This will help the specialist understand the purpose of the referral.
03
Include the name of the healthcare provider who is referring the patient for the screening. This could be their primary care physician, an audiologist, or any other healthcare professional involved in their care. Include their contact information as well.
04
If the patient has any medical insurance, provide their insurance details. This includes the name of the insurance company, policy number, and any other relevant information. This will ensure a smooth process and help determine any coverage or payment requirements.
05
Finally, sign and date the referral form. This verifies that the information provided is accurate and that it has been authorized by the healthcare provider. For electronic forms, an electronic signature may be used.
Regarding who needs a hearing screening referral, it is typically recommended for individuals who are experiencing hearing difficulties, have a family history of hearing loss, or have been exposed to prolonged or intense noise. Additionally, individuals with certain medical conditions or receiving specific treatments may also require a referral. It is best to consult with a healthcare professional to determine if a hearing screening referral is necessary for a particular individual.
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