Get Weisskopf Center Referral Form

This guide provides you with clear, step-by-step instructions on completing the Weisskopf Center Referral Form online. By following these steps, you will ensure that all necessary information is accurately submitted for the referral process.

Follow the steps to complete the Weisskopf Center Referral Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section. Enter the date of referral, WCEC chart number, account number, patient's name (last, first, middle), birthdate, and social security number. Provide the patient's address including street, city, state, and zip code. Additionally, include home and cell phone numbers, county, and indicate if family will need an interpreter.
3. Next, complete the parent/legal guardian information. Fill in the names of the mother, father, and legal guardian (if applicable) along with their relationship to the child. If the legal guardian's address differs from the child's, include that information as well.
4. In the insurance/financial information section, list the details for insurance carrier #1. Fill in the effective date, subscriber ID number, group number, subscriber name, insurance carrier telephone number, date of birth, and insurance address. Repeat this process for insurance carrier #2 if applicable.
5. Describe the reason for referral by detailing the presenting concerns, indicating the services requested (evaluation or treatment), and any current or rule-out diagnoses.
6. Select the requested evaluation site by checking the appropriate box for WCEC, Star Program, Outreach Clinic, or Genetics.
7. For referring physician information, indicate whether you are the patient’s primary care physician. If not, provide the primary care physician's name and phone number. Fill in your own details including name, signature, address, phone numbers, and any relevant identification numbers.
8. Finally, ensure that all required fields for billing purposes are completed. This includes the doctor’s Medicaid ID, KENPAC, taxonomy code, passport ID, UPIN, and NPI.
9. After filling out all sections of the form, review the information for accuracy and completeness. You can then save changes, download, print, or share the form as needed.

Complete your Weisskopf Center Referral Form online today to ensure a smooth referral process.