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Get Virginia Mason Referral Form
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How to fill out the Virginia Mason Referral Form online
Filling out the Virginia Mason Referral Form online is a straightforward process that ensures an efficient referral for patients seeking gastrointestinal and hepatology services. This guide provides step-by-step instructions to help users complete the form accurately and effectively.
Follow the steps to successfully complete the Virginia Mason Referral Form.
- Click ‘Get Form’ button to acquire the referral form and open it for editing.
- Begin by filling in the Referring Provider section. Provide your name, clinic name, clinic contact, and all relevant contact information including phone, fax, and email. Select 'This is a self-referral' if applicable.
- Next, move to the Patient Information section. Fill out the patient's full name, date of birth, and gender. Indicate whether the patient needs an interpreter and provide the patient's address, city, state, zip, and phone numbers. Include insurance details by specifying the primary and secondary insurance providers and their respective IDs.
- In the Referral Details section, select the level of urgency for the referral. Options include 'Emergent,' '1 Week,' '2 Weeks,' or 'Next Available Appointment.' Be specific about the provider requested and the reason for referral, such as ERCP, EUS, liver issues, or other specified conditions.
- Ensure that all fields marked as required are completed for the referral to be processed. This includes providing supporting documents such as H&P/Referral Dictation, Medication/Allergy List, GI Procedures Report, Lab Results, Radiology Reports, and Pathology Reports.
- Finally, save any changes made to the form, and download or print a copy. You may also share the form as needed, and be sure to fax it to the designated number at (206) 625-7195 along with the required documents.
Complete the Virginia Mason Referral Form online today for a seamless referral process.
Referring a patient involves filling out a Virginia Mason Referral Form with the patient's information and detailing the medical issue that requires specialist attention. Make sure to send the form to the appropriate specialist to initiate the referral process. Resources like US Legal Forms can provide you with a reliable template to ensure all necessary details are captured.
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