Get Request For Consultation Form - University Of Michigan Health System - Med Umich

Filling out the Request For Consultation Form for the University of Michigan Health System ensures you provide all necessary details for a smooth referral process. This guide offers clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully fill out the form online:

1. Press the ‘Get Form’ button to acquire the form and access it for completion.
2. Enter today’s date in the designated field at the top of the form.
3. In Section 1, provide the patient information: fill in the UM Registration number (for internal use), patient's name (printed), address, city/state/zip code, date of birth, sex (select either F or M), telephone numbers (home and work), and the patient’s social security number.
4. Indicate the patient’s insurance information, selecting the appropriate option such as M-CARE, BCN, or other types listed. If referral authorization is necessary, ensure to fax to the specified number.
5. In Section 2, fill out the referring physician's information. Include the physician's name, UPIN number, address, city/state/zip code, telephone number, and fax number. Repeat this for the primary care physician.
6. Section 3 requires a detailed patient history. Note the diagnosis, rule out any potential conditions, and list any relevant studies along with their completion dates. Make sure to indicate the location where these tests were performed.
7. Summarize the brief medical history of the patient as required in Section 3.
8. For UMHS staff, there is a section for recommendations; however, this is for internal use only.
9. Once all sections are filled out, review the information for completeness and accuracy. Finally, fax the completed form, along with any medical documentation, to the provided fax number (734-936-8067).

Take a moment to complete your Request For Consultation Form online to facilitate your referral process.