Get General Referral Form New Patient Existing Q

Filling out the General Referral Form New Patient Existing Q online is an essential step for ensuring smooth communication and accurate processing of patient referrals. This guide provides clear, step-by-step instructions to help you complete the form effectively and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in the designated editor.
2. In the Patient Information section, enter the patient's name in the provided field. Make sure to fill in all required details such as the Social Security number (SS#) and date of birth (DOB) in the specified formats.
3. Indicate the patient’s gender by selecting the appropriate option (Male or Female). Fill in the address, including city, state, and zip code.
4. Provide the patient's weight and height, as well as contact information including home phone, work phone, cell phone, and email.
5. In the Medical Information section, detail the diagnosis by entering both the primary and secondary ICD-9 codes if applicable. Also, list any known allergies the patient may have.
6. In the Prescribing Information section, insert allergies related to medications, followed by the medication name, strength, quantity, and number of refills requested.
7. Complete the Insurance Information section by entering details regarding the primary and secondary insurance providers. Include the insured person's name, ID number, policy/group number, and contact phone number.
8. Attach a copy of the patient's insurance card, both front and back, as required.
9. In the Prescriber Information section, enter the prescriber's name, contact name, office or clinic name, and address. Ensure you include the phone and fax numbers as well as any necessary credentials like NPI, DEA, and state license numbers.
10. After completing all sections, review the form for accuracy. You can then save the changes, download, print, or share the form as needed.

Complete your documents online seamlessly and efficiently.