Get Patient Referral Form - Pacific Infusion Center

Completing the Patient Referral Form for the Pacific Infusion Center can seem daunting, but with the right guidance, you can navigate it smoothly. This comprehensive guide provides step-by-step instructions to help you efficiently fill out the form online.

Follow the steps to successfully complete the Patient Referral Form.

1. Press the ‘Get Form’ button to access the Patient Referral Form and open it for editing.
2. Begin by filling in the practitioner information. This includes entering the practitioner's name, DEA number, Tax ID number, and state license number in the appropriate fields.
3. Next, provide the patient's information. Ensure you include the patient's full name, date of birth, social security number, and gender. Note that you should provide a physical address, as P.O. boxes are not acceptable.
4. Complete the insurance information section. You will need to enter details such as the primary insurance name, policyholder's name, their date of birth, and policy number. Make sure to have a copy of the insurance card, both front and back, to include with the form.
5. In the medical information section, indicate any prior history and treatments the patient has received. Be thorough, as this information is critical for appropriate care decisions.
6. Fill out the initial dosing and maintenance dosing information. Specify which dosing format the patient is receiving and include all necessary details, such as quantities.
7. Review the entire form to ensure all fields are accurately completed. Take note of any required signatures and dates, especially in the authorization section.
8. Once you have reviewed and confirmed that all information is correct, you can save the changes, download the completed form, print a copy, or share it as needed.

Start completing the Patient Referral Form online now to ensure timely processing of your referral.