MEDICAL REFERRAL FORM TEMPLATE

RETURN COMPLETED REFERRAL REQUEST FORM TO	REFERRED BY	MEDICAL REFERRAL FORM
ATTENTION	REFERRING MD	YOUR LOGO
PHONE	SPECIALTY
FAX	SIGNATURE
EMAIL	PHONE
FORM COMPLETED BY	FAX
NAME	EMAIL
PHONE	PCP if different
DATE	PCP PHONE
PATIENT INFORMATION	SERVICE REQUESTED	INSURANCE INFORMATION
LAST NAME	REASON FOR REFERRAL	AUTHORIZATION REQUIRED?	YES
FIRST NAME & M.I.	NO
DATE OF BIRTH	AUTH. NO.
FEMALE / MALE	NO. of VISITS
INTERPRETER REQ.?	AUTH. EXP. DATE
LANGUAGE REQ.	PPO	INSURANCE PLAN
GUARDIAN NAME	HMO
Relationship to Pat.	OTHER
PATIENT ADDRESS	PATIENT AWARE of reason for referral? If not, please explain.	INSURANCE ID
MEDICAL GROUP
PHONE
CELL PHONE	SERVICE / SPECIALTY REQUESTED	FAX
HOME PHONE	INS. HOLDER NAME
WORK PHONE	PHYSICIAN REQUESTED	Relationship to Pat.
EMAIL	DATE OF BIRTH
REFERRAL DIAGNOSIS	TYPE OF SERVICE REQUESTED	ADDITIONAL COMMENTS
REFERRAL DIAGNOSIS	CONSULTATION
TRANSFER OF CARE new patient evaluation / management
ICD-9

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