Follow the steps to successfully complete the referral form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering the date at the top of the form. This identifies when the referral is being made.
3. Provide the referring doctor's information, including their name, address, phone numbers, fax number, and email. This section is crucial for communication about the referral.
4. In the patient information section, fill out the patient's first name, last name, address, and phone number. Indicate if it is okay to leave voice messages at this number by checking 'Yes' or 'No'.
5. List the best days and times to reach the patient, ensuring that they can be contacted most conveniently.
6. Document the patient's insurance provider and whether substance abuse treatment is covered by the plan by checking 'Yes' or 'No/Unknown'.
7. Provide the reason for the referral. This helps clarify the urgency and purpose of the referral.
8. Detail the patient's substance history, including any current or past addiction or abuse of alcohol, prescription drugs, and illegal drugs, as well as any treatment history.
9. List any medications the patient is currently taking, ensuring a clear overview of their treatment regimen.
10. On the second page, enter the patient’s name and the current date again.
11. Record any pertinent test results and dates, including Hepatitis C, liver enzymes, and urine tests.
12. Include any other relevant medical history, such as psychiatric diagnoses.
13. Finally, the referral and patient signatures are required at the bottom of the form to validate the referral.
14. Once the form is completed, you can save your changes, download, print, or share the form as needed.

Complete your referral forms online today for streamlined access to substance abuse treatment.