Get Referral Made To Diagnostex For Dysphagia Consult...

Filling out the Referral Made To DIAGNOSTEX for dysphagia consult is an important step in ensuring that individuals receive the necessary evaluations for swallowing difficulties. This guide will provide clear, step-by-step instructions to assist users in completing the form accurately and effectively online.

Follow the steps to complete the referral form with ease.

1. Press the ‘Get Form’ button to access the referral form and open it in your document editor.
2. Begin by filling out the patient information section, which includes name, age, date of birth, sex, address, and Social Security number.
3. Provide the unit or room number, height, weight, and name of the ordering physician. Indicate mobility aids used, such as wheelchair or walker.
4. Complete the facility contact information, including the requesting facility name, city, and phone number.
5. In the insurance coverage section, check the applicable boxes for types of insurance, and provide the necessary policy and prior authorization numbers.
6. Specify any necessity for mobile service based on the listed concerns regarding transportation.
7. For the reasons for the consult, check all applicable options such as coughing, choking, or dehydration.
8. Indicate the onset duration of dysphagia and whether there are contact precautions needed, including the reason if applicable.
9. Select all relevant medical history or diagnoses related to dysphagia.
10. Describe the current diet and consistencies, as well as any previous evaluations that the patient may have undergone.
11. Complete additional sections regarding cognition and pulmonary status as necessary.
12. Before final submission, ensure all sections are filled out accurately and that you have provided all necessary documentation. Sign and date the order.
13. Once completed, save the changes, download, or print the form as required for submission.

Start filling out the referral form online to ensure timely consultation for dysphagia.