Follow the steps to complete the form accurately

1. Press the ‘Get Form’ button to acquire the form, which will then appear in your document editor.
2. Enter the date of referral in the designated field at the top. This helps to track the timeline of requests for services.
3. Fill out the primary insurance details. Include the name of the insurance provider and the policy or member number for verification.
4. Provide patient information, including the patient's name (last, first, and middle initial), complete address, preferred language, and date of birth in the correct format (MM/DD/YY).
5. Complete the contact information section with the patient's phone numbers, ensuring both home and cell numbers are included if applicable.
6. If applicable, fill out the secondary insurance information, similar to the primary insurance section. This ensures all possible coverage is accounted for.
7. In the primary or requesting provider section, input the provider’s name, specialty, institution/group name, and provider ID. Include the office address and phone number for further verification.
8. Next, in the consultant/facility provider section, enter the name of the consulting provider, along with Johns Hopkins Hospital’s institution/group name and address, ensuring accuracy in the contact details.
9. Indicate the specialty of referral (GI) and fill out the phone number for easy communication regarding the patient's case.
10. Provide information about the procedure requested and the reason for referral. This section may require additional documentation for outside referrals.
11. Finally, provide the signature of the individual completing the form and any necessary authorizations, if required.
12. Review the completed form for accuracy before saving changes, downloading, printing, or sharing the document.

Start filling out the John Hopkind Endoscopy Referral Form online now to streamline your referral process.