Universal Referral Form

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Date Referred:                                     
Referred BY                                          Supervising MD                              Phone:                       Fax:                         
                                                                                                                                                                                    
Referred TO:                                                                                          Fax #:                                                          
Office Address:                                                                                    Phone #:                                                      
                                                                                                                                                                                    
Patient Name                                                                                        DOB:                           Gender:  F / M 
            Parent’s Name (if patient is a minor)                                                                              
Home Phone:                                        Work Phone:                                  Cell Phone:                                             
Patient’s Address:                                                                                                                                                     
Authorization:  □  Not Required    □ Requested/Pending    □ Requested/Obtained Auth #                                           
Primary Medical Insurance:                                                                    Subscriber ID#:                                            
Secondary Medical Insurance:                                                                Subscriber ID#:                                            
Worker’s Comp Insurance (if any):                                                          Employer:                                                    
        Adjustor                                        Claim #                                      Date of Injury:                                              
      Comp Address                                                                                Comp Telephone                                          

For Urgent Referrals (need to be seen within a week), the referring clinician should call the specialist. 

□   Reason for Referral (Symptoms of Concern) (also send related medical records or dictated summary)
□  Please advise on the patient’s care   □   Please assume care of this patient
Please ask patient to provide related records from other specialists, if any.

 

                                               
□  Relevant lab tests and imaging results  (also send related medical records)

 

 

□  Medications and Dosages tried and outcomes (if not specifically noted in medical records sent with referral)
     Please ask patient to bring his/her complete medication list with dosages (or bring the meds themselves) to their appointment.

 

                                                                                                                                                                                
Appointment is scheduled with:                                                  on                                        at                   arrival time
Prior to appointment please obtain the following information, tests, etc:             Date faxed to referring clinician:          

 

 

□  We will contact patient to schedule  □ Please have patient call to schedule  □  Please call patient to schedule