Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the patient name in the designated field, and ensure to include their telephone number and the date of completion.
3. Fill in the patient's insurance information, including the policy number and group number, along with the date of birth.
4. Provide details regarding workers compensation, including the attorney's name and authorization number, if applicable.
5. Specify the diagnosis by writing it out or including the ICD-10 code in the required field.
6. The physician must sign in the required space and print their name below the signature.
7. Complete the preliminary reading contact telephone number and the after-hours contact number.
8. Fill out the address of the patient, along with their telephone and fax numbers.
9. Indicate if the patient is to take a CD with them by checking the appropriate box.
10. Select the necessary tests such as CT scan, MRI, or other services needed by checking the corresponding boxes.
11. Complete the appointment location by selecting the appropriate facility as per the patient’s preference.
12. Provide the patient work and cell phone numbers, along with appointment date and time.
13. Finally, enter today’s date and your initials in the required fields before proceeding to save changes.
14. Upon completion, you can save the form, download it, print it, or share it as needed.

Take the next step in efficient document management by filling out your forms online today.