Get Patient Referral Form - Shriners Hospitals For Children

Filling out the Patient Referral Form for Shriners Hospitals For Children is a straightforward process that helps initiate necessary care for children in need. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete your form online.

1. Press the ‘Get Form’ button to access the Patient Referral Form and open it in your preferred online environment.
2. Begin filling out the 'Patient Information' section by entering the patient's name, sex, social security number, date of birth, and diagnosis. Be sure to specify if it is a sports injury.
3. Next, enter the names and dates of birth for the mother or guardian and father or guardian in the appropriate fields.
4. Complete the mailing address fields with the patient’s street address, city, state, and zip code. Provide the home phone number and both parents' cell phone and work numbers as directed.
5. In the 'Referring Healthcare Provider' section, fill in the physician's name, confirm if they are the primary care physician, and if not, complete the additional specified details.
6. Attach copies of the insurance card and parent identification as required, and fill in the name of the insurance provider along with the subscriber information.
7. Next, detail the primary care physician’s name, specialty, address, phone number, and email address.
8. After completing all sections, review the form for accuracy and completeness to ensure all required information is included.
9. Finally, save your changes, and choose to download, print, or share the completed form as needed. Remember to fax the completed form to (916) 453-2395 or mail it as per the instructions provided.

Take the next step and complete your Patient Referral Form online today.