Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the referral form and open it for editing.
2. Begin with the referring physician information section. Fill in the referring physician’s name, date, office address, UPIN number, city, state, zip code, and telephone number. Ensure all details are accurate and up-to-date.
3. Next, move to the patient information section. Enter the patient’s first name, middle initial, last name, and their Mayo Clinic number if available. Fill out the address, county, city, state, and home and work telephone numbers.
4. Provide the date of birth in the specified format (MO-DAY-YEAR). If the patient is a minor, include the parent’s name. Additionally, note the maiden name and spouse’s first name if applicable.
5. Indicate whether the patient has medical insurance and if they belong to an HMO by selecting yes or no. Also, clarify if there is any involvement of workers’ compensation or litigation.
6. If applicable, specify the reason for referral, including any specific symptoms or diagnosis, along with the onset and duration of these issues. Record the date(s) of any previous surgeries or testing conducted.
7. In the appointment request section, indicate the requested appointment date(s) and preference for scheduling urgency (emergent, urgent, routine).
8. Identify the specific consultant requested for the patient’s referral, if necessary.
9. Once all sections are filled out, review the information for accuracy. Users can then choose to save changes, send the form electronically, download, print, or share the completed document.

Ensure your patient receives timely care by completing the Mayo Clinic Referral Form online today.