Get Patient Referral Form - University Of Maryland Medical Center - Umm

Completing the patient referral form is an essential step for ensuring patients receive appropriate care at the University of Maryland Children's Hospital. This guide provides clear instructions to help you navigate the form efficiently and accurately.

Follow the steps to complete the form online.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editor.
2. In the section titled 'Patient Information', input the patient's full name, date of birth, and phone number. Make sure to use the appropriate format for each field.
3. Select the relevant specialty for the patient's referral by checking the appropriate box from the provided list, which includes options such as cardiology, endocrinology, and more.
4. Indicate the patient's gender by marking either 'MALE' or 'FEMALE'.
5. Input the parent or guardian's name in the designated section to ensure we have proper contact information.
6. Provide the insurance information by filling in the name of the insurance provider. This will assist in processing the referral.
7. Select the desired appointment priority by checking one of the options: 'Urgent—within 48 hours', 'Priority—within 2 weeks', or 'Routine—within 30 days'.
8. Describe the diagnosis or reason for the visit in the space provided. If applicable, add the ICD-9 code, which is optional.
9. Complete the 'Referring Physician' section with your name and phone number, ensuring clear communication for follow-up.
10. Finally, sign the form in the area designated for the physician's signature. This confirms the referral request before you submit.
11. Once all fields are completed, you can save your changes, download, print, or share the form as necessary.

Complete the patient referral form online today to ensure timely care for your patients.