Get New Patient Referral Checklist

Filling out the NEW PATIENT REFERRAL CHECKLIST accurately is vital for ensuring a smooth referral process. This guide provides clear, step-by-step instructions designed to help you complete the form online with ease.

Follow the steps to complete the checklist effectively.

1. Click the ‘Get Form’ button to access the NEW PATIENT REFERRAL CHECKLIST and open it in your preferred viewing application.
2. Begin by entering the referral to section. If there is a specific physician preference, provide their name in the designated field.
3. Fill in the patient’s information, including their name, date of birth, social security number, and MUSC medical record number, if applicable.
4. Complete the patient's contact information fields, including address, cell phone number, home phone number, email address, and an alternate contact number, along with their relation to the patient.
5. Indicate the patient's insurance details by selecting the appropriate option: Private insurance by entering the provider name and ID number, Medicaid or Medicare by completing the policy/group number, or selecting options for self-pay or disability.
6. Enter the referring physician's name and specialty, followed by their office address, phone number, and fax number.
7. List the patient’s primary care physician name and phone number in the provided fields.
8. Describe the reason for the referral clearly in the reason for referral section, followed by any additional patient history that may be relevant.
9. Indicate the physician preference or note if the first available option should be chosen.
10. For efficient scheduling, call the provided number to obtain the appointment date and time, and note that certain specified reports and records need to be faxed to the designated number.
11. Select the appropriate option regarding the patient's imaging and ensure that any necessary outside imaging is prepared for the first appointment.
12. Complete the form by filling in your name, phone number, and date in the completed by section.
13. After completing the form, you can save changes, download, print, or share the NEW PATIENT REFERRAL CHECKLIST as needed.

Complete your documents online to ensure a seamless referral process for your patients.