Follow the steps to fill out the Fax Referral Form accurately.

1. Click the ‘Get Form’ button to access the Fax Referral Form and open it in your chosen document editor.
2. Fill in the date at the top of the form, ensuring it accurately reflects the current date of submission.
3. Select a facility preference by checking the appropriate box: Kettering, Sycamore, or First Available.
4. Enter the referring physician's name in the designated field to ensure proper identification of the referring provider.
5. Provide the referring physician's office phone number to facilitate communication.
6. Fill in the patient's full name as it appears on their identification documents.
7. Record the patient's date of birth in the specified format to ensure accurate age verification.
8. Input the patient's home phone number, followed by their work phone number, if available. This will help in scheduling consultations comfortably.
9. Indicate the patient's insurance details to confirm coverage eligibility.
10. Specify the diagnosis relevant to the referral, which will help the consulting physicians in their assessment.
11. Once all fields have been completed, review the form for accuracy and completeness before finalizing it.
12. You can save any changes made to the document, download it for your records, print it, or share it as needed.

Start completing the Fax Referral Form online to ensure timely patient referrals.