Get Referral Form - Department Of Neurology And Opthalmology

Filling out the referral form for the Department of Neurology and Ophthalmology is an essential step in seeking specialized medical care. This guide will provide you with a clear and step-by-step approach to ensure all required information is properly submitted to facilitate a timely appointment.

Follow the steps to successfully complete the referral form online.

1. Click ‘Get Form’ button to download the referral form and open it in your preferred online document editor.
2. Begin by checking the preferred specialty and/or provider from the options provided. Ensure you select the appropriate category that best fits the patient’s needs.
3. Fill in the patient’s referral date, last name, first name, and Social Security number, as this information is critical for identifying the individual.
4. Indicate the patient’s sex and date of birth, followed by the complete address, including apartment number, city, and ZIP code.
5. Provide contact numbers: home, work, cell, and alternative, to ensure timely communication regarding the appointment.
6. If applicable, fill in the parent or guardian contact information. Include their name and phone numbers.
7. Document the diagnosis and symptoms clearly to assist the medical team in understanding the patient's condition.
8. Complete the insurance information section accurately. A copy of the insurance card must be attached, and all requested details must be filled in.
9. Specify if insurance authorization is required and provide the authorization number along with the number of visits allowed.
10. Input the primary care physician's information, including their name, phone number, and fax number.
11. Fill in the referring physician’s information, ensuring to provide the contact person's name and their phone number as well.
12. Once all fields are completed, review the form for accuracy. Save changes, then download, print, or share the completed form as necessary.

Complete your referral form online today to ensure prompt assistance with your neurology and ophthalmology needs.