Get Referral Request Form - Marshfield Clinic - Marshfieldclinic

Filling out the Referral Request Form for Marshfield Clinic is an important step in facilitating patient referrals to specialists. This guide provides clear, step-by-step instructions to ensure the form is completed accurately and efficiently.

Follow the steps to successfully complete your referral request online.

1. Click ‘Get Form’ button to access the referral request form and open it in the editing tool.
2. Enter the date of the referral at the top of the form to establish the timeline.
3. Provide the referring provider's name, phone number, and fax number to ensure communication during the referral process.
4. Fill in the practice name and address of the referring provider to help identify the provider's location.
5. Complete the patient's name and date of birth, ensuring that this information matches their official identification.
6. Indicate whether the patient has received medical care under another name and provide that name if applicable.
7. Input the patient's contact number, ensuring it's a number where they can be reached easily.
8. Complete the patient’s home address to verify their contact information.
9. Specify the specialty to which the patient is being referred, along with any applicable information for the Pain Clinic or Behavioral Health.
10. Detail the urgency of the referral, whether it is required within days, weeks, or as scheduled.
11. Provide the diagnosis or complaint accurately to assist with the referral's purpose.
12. Indicate if the referral is a result of a work-related injury or accident, and include necessary details like the employer's name and date of injury if applicable.
13. List any relevant labs or imaging studies related to the patient's condition, including date, study type, and location.
14. Add any additional information regarding patient needs such as special accommodations, interpreter requirements, or any impairments.
15. Once all fields are completed, review the form for accuracy, then save changes, download, print, or share the document as needed.

Take the next step in patient care by completing the Referral Request Form online today.