Get Physician Referral Form - Keck School Of Medicine Of Usc

Completing the Physician Referral Form from the Keck School of Medicine of USC is an essential step for referring patients to specialized care. This guide offers clear, step-by-step instructions to help you accurately fill out the form online.

Follow the steps to complete the form online.

1. Click the ‘Get Form’ button to obtain the Physician Referral Form and open it in your preferred online editor.
2. In the referring MD section, enter the name of the physician making the referral and specify their specialty. Include the address, office contact person's name, telephone number, and fax number to ensure successful communication.
3. Fill out the patient information section with the patient’s last and first name, date of birth (DOB), and contact numbers. Additionally, provide their mailing address, including city, state, and ZIP code.
4. In the diagnosis field, clearly state the patient’s diagnosis, followed by the corresponding ICD10 code. This is vital for proper processing and understanding of the patient's condition.
5. Select the specialty area required for referral by checking the appropriate box and indicating the urgency of the referral (urgent, within one week, within two to four weeks).
6. Document any relevant medical history by circling applicable conditions listed, such as sleep apnea, diabetes, or mobility issues, to provide the medical team with comprehensive background information.
7. Lastly, make sure to provide information about other care providers involved in the patient's treatment, including names and contact information.
8. After completing the form, review all entries for accuracy, and save any changes. You can then download, print, or share the form as needed for submission.

Start filling out your Physician Referral Form online today to ensure prompt and effective patient care.