Get New Patient Referral Form.docx. Adobe Designer Template - Med Unc

Filling out the New Patient Referral Form is a crucial step in facilitating the referral process for new patients. This guide provides clear and supportive instructions to ensure that you can complete the form accurately and efficiently.

Follow the steps to complete the New Patient Referral Form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter the patient's first name, last name, and middle name or initial in the appropriate fields. Ensure all names are spelled correctly.
3. Fill in the patient's date of birth (DOB) and gender by selecting one of the provided options: Male, Female, or indicating if the patient is pediatric by providing the name of the parent or guardian if applicable.
4. Complete the patient's address, including the city, state, and zip code. Provide a valid home telephone number, work number, and cellular number.
5. Specify the insurance company details for the patient, ensuring all information is accurate.
6. Indicate the referral reason by selecting one of the options: Consultation, Transfer of Care, or Second Opinion, and provide the chief complaint along with signs and symptoms.
7. Fill in the date of onset for the patient's condition, if applicable.
8. Provide the referring physician's information, including their specialty, practice name, address, UNC MD code, telephone number, and the contact person's details within the office.
9. List the primary care physician's name and their telephone number.
10. To expedite the appointment, fax the specified documents with the referral to the provided fax number, making sure to include relevant operative reports, imaging formal reports, and other necessary records.
11. Complete the sections marked for internal use, including the date received, triaged by, date patient contacted, appointment date, and physician details.
12. Review all input for accuracy before saving your changes. You can then download, print, or share the form as required.

Complete your documents online and streamline the referral process today.