Get Physician Referral Fax Form Fax # 954.355.4881 - Broward Health - Browardhealth

The Physician Referral Fax Form is crucial for facilitating patient referrals to the Broward Health Heart Valve Center. This guide will help you navigate each section of the form and ensure that all necessary information is accurately provided.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Fill in the date at the top of the form in the designated space.
3. In the 'Dr.' section, enter the name of the referring physician. Ensure the spelling is correct to avoid any issues.
4. Enter the patient's full name in the 'Patient Name' field, confirming that it matches their identification.
5. Provide the patient's Social Security number in the space provided, ensuring accuracy for processing.
6. Fill in the patient's date of birth (DOB) using the format MM/DD/YYYY.
7. List the patient’s phone number and cell number, if available, for ease of contact.
8. Specify the patient's insurance information clearly in the relevant section.
9. In the symptoms section, briefly describe the patient's symptoms related to their valve condition.
10. Check off any tests that have already been performed by marking the appropriate boxes: EKG, ECHO (TT / TEE), CT SCAN, MRI, CATH, CXR, or LABS.
11. Indicate the total number of pages being faxed by writing the number in the designated space.
12. If you have any questions, contact Julie Delongy at 954.761.BEAT.
13. After completing the form, save the changes, download, print, or share the form as necessary.

Complete your documents online with confidence and ensure timely referrals.