Get Patient Referral Form T 765.448.8200 F 765.448.7631 ...

Filling out the Patient Referral Form is an essential step for ensuring that patients receive the specialized care they need. This guide will provide you with clear instructions on how to accurately complete the form online, making the process smoother and more efficient.

Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to obtain the document and open it in your preferred editor.
2. Fill in the referring physician’s details, including their name and signature, as well as their phone number and fax number.
3. Indicate the pulmonologist's name, along with the appointment date and time.
4. Complete the patient’s information by entering their name, phone number, and medical record number (or date of birth).
5. Select the appropriate diagnosis for referral from the provided list, such as asthma, COPD, or lung cancer.
6. Choose whether you are requesting an opinion (consult only) or transferring management of a pulmonary condition for a new patient.
7. Specify which additional information you can fax before the appointment, including chest X-ray or CT images, if available.
8. Answer the additional questions regarding the patient’s medical history, including hospitalizations for lung issues and sleep studies.
9. Indicate whether the patient uses a CPAP or BIPAP machine, wears oxygen, and has received flu and pneumonia vaccines.
10. Review all entered information for accuracy, make any necessary changes, and then save, download, print, or share the form as needed.

Complete your documents online today for a seamless referral process.