Get Print And Fax A Patient Referral Form - Med Unc

Filling out the Print And Fax A Patient Referral Form - Med Unc online is a straightforward process that can facilitate patient referrals efficiently. This guide provides step-by-step instructions to assist users in completing the form accurately and easily.

Follow the steps to complete the referral form online.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editor.
2. In the first section, enter the patient's name in the designated field.
3. Provide the patient's preferred phone number to ensure they can be reached easily.
4. Fill in the patient's date of birth (DOB) using the format of month, day, and year.
5. If applicable, include the patient's medical record number (MRN) from UNC. If the patient has not been seen before, indicate this so they can be registered during appointment scheduling.
6. Select the reason for referral by checking the appropriate box. Options include kidney stones, hematuria, urinary incontinence, erectile dysfunction, BPH, vasectomy, hernia repair, bladder infection, urinary tract infections, elevated PSA, suspected cancer, or other — please specify.
7. Enter the name and practice of the referring physician in the respective section.
8. Identify the contact person who is completing this form and list their contact phone number.
9. Indicate the patient's insurance information by checking the appropriate option. If using private insurance, include the specific insurer's name.
10. Review all entered information for accuracy before finalizing the form.
11. Once completed, you can save changes, download, print, or share the form as necessary.

Start completing your forms online to ensure timely patient referrals.