Get Mohs Referral Form - Mediasrc Bcm

Filling out the Mohs Referral Form - Mediasrc Bcm online is an essential step for a seamless referral process. This guide will walk you through each section and field of the form, ensuring all necessary information is accurately provided.

Follow the steps to complete the Mohs Referral Form with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date on the form, ensuring it is current and accurate.
3. Select the physician you are requesting: Mohsin Mir, M.D., Ida Orengo, M.D., or First Available by marking the corresponding checkbox.
4. Provide the patient's details, including their name, date of birth, and phone number.
5. Indicate the patient's address for correspondence.
6. Specify if this is a new patient to the Baylor Clinic by selecting 'Yes' or 'No.'
7. Attach the pathology report, filling in the diagnosis information, and indicate the location and size of any lesions.
8. Select the procedures requested by checking the appropriate boxes (Mohs surgery, biopsy, excision, or other).
9. Fill out the referring physician's name and office address, along with their phone and fax numbers.
10. Review all entered information for accuracy, then save your changes. You may choose to download, print, or share the completed form.

Get started on completing the Mohs Referral Form online today!