Get Form For Referring Providers - Allergy/asthma Specialists W. Mi

Filling out the Form For Referring Providers for Allergy/Asthma Specialists in West Michigan is an essential step in ensuring that patients receive the care they need. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form online with ease.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Fill in the appointment section, including the preferred date and time for the patient’s appointment. Indicate whether the appointment is at the Grand Rapids Office or the Greenville Office.
3. Enter the referring physician's or provider's details in the appropriate field, including their name and contact number.
4. Provide the patient's full name by filling out the first, middle initial, and last name sections. Enter their date of birth and select their sex.
5. Indicate the patient's marital status by checking the appropriate box: Married, Single, or Child.
6. Specify the reason for the patient's visit by checking one or more relevant boxes, such as asthma, wheezing, nasal allergies, or other conditions.
7. Answer the question about whether the patient is currently taking antihistamines. If yes, provide instructions to advise them to stop antihistamines one week prior to the appointment.
8. Fill in the patient's home address, including city, state, and zip code.
9. Enter the daytime telephone number of the patient for contact purposes.
10. If the patient is a minor, provide the parent's name.
11. Complete the primary insurance section by entering the name of the insurance company, phone number, policy holder's name, date of birth, contract number, group number, and social security number.
12. If applicable, fill in the secondary insurance details in the same manner as the primary insurance.
13. Enter the co-pay and deductible amounts, along with information on whether the deductible has been met.
14. Ensure you fax any pertinent medical records before the patient’s appointment to the specified fax number.
15. Once all fields are completed, save your changes, and download, print, or share the form as needed.

Complete your documents online today to ensure timely appointments for your patients.