Get Marshfield Clinic Referral Request - Marshfieldclinic

Completing the Marshfield Clinic Referral Request form is an important step in ensuring that patients receive the necessary referrals for their medical care. This guide offers clear and detailed instructions on how to accurately fill out the form online.

Follow the steps to successfully complete your referral request.

1. Click ‘Get Form’ button to obtain the referral request form and open it in the editor.
2. Begin by entering the date in the designated field at the top of the form.
3. Fill in the referring provider's name and contact details, including phone number and fax number.
4. Provide the address and practice name of the referring provider for records.
5. Next, enter the patient's name and date of birth to identify the individual requiring the referral.
6. Indicate if the patient has received medical care under another name by checking 'Yes' or 'No' and providing the alternate name if applicable.
7. Input the patient's contact number and, if available, an alternate phone number.
8. Complete the patient's home address to ensure accurate communication.
9. Document the primary care provider or facility the patient is currently associated with.
10. Specify the specialty to which the patient is being referred.
11. If applicable, indicate the type of services needed at the Pain Clinic (medication management, potential injection, or spine assessment).
12. If referring to a specific provider, enter their full name and the facility to which they belong.
13. Note the urgency of the referral, specifying if it is needed urgently, within days or weeks, or if it is elective.
14. Fill in the diagnosis or complaint that mandates the referral to provide context to the receiving provider.
15. Indicate if the referral relates to a work-related injury or illness, and if so, include the employer's name and the date of injury.
16. Document any relevant labs or imaging studies, including the date, type of study, and location.
17. Provide additional information regarding any special needs the patient may have, such as language interpretation services or mobility requirements.
18. Once all fields are completed, review the information for accuracy. Save any changes, and download or print the form as necessary for submission.

Take the first step towards efficient healthcare management by completing your referral request online today.