Get Podiatry Referral Form

Completing the Podiatry Referral Form online is a straightforward process designed to streamline patient referrals to podiatry services. This guide provides a detailed walkthrough to help you accurately fill out each section of the form, ensuring all necessary information is provided.

Follow the steps to successfully fill out the Podiatry Referral Form

1. Press the 'Get Form' button to access the Podiatry Referral Form and open it in your document editor.
2. Begin with the patient information section. Fill in the patient's name, date of birth, and contact number. Complete their address and ensure to specify the city, state, and zip code.
3. Include the applicable diagnosis codes or descriptions. If available, it is important to fax a copy of the face sheet for the patient’s records.
4. Move to the prescription information. Choose the appropriate items for antifungal treatments by selecting from the checkboxes. Specify the quantity, refill instructions, and provide clear directions for use.
5. Continue to the eczema and rash section. Similarly, select the relevant treatments and again fill out the quantity, refill information, and directions for use.
6. Complete the keratosis and warts section by selecting the appropriate treatments and entering the required details.
7. Fill in the nail care section, choosing any necessary treatments and detailing quantity, refills, and directions.
8. Proceed to the wound care, pain, and inflammation section. Select the relevant treatments and provide the required information.
9. If there are any other oral, topical, or compounded formulas, list them and fill in the quantity, refills, and directions as needed.
10. It is necessary to fax a copy of the front and back of all insurance cards along with the completed form.
11. Next, complete the prescribing physician section. Fill in the physician's name, phone number, fax, and NPI/DEA number. Date the form and secure the physician's signature.
12. Review all entered information to ensure accuracy and completeness before finalizing the form. At the end of the process, you can save changes, download, print, or share the filled-out form as required.

Start filling out the Podiatry Referral Form online today to ensure seamless processing of referrals.