Get Duke Referral Form

Completing the Duke Referral Form online is essential for scheduling a radiology procedure with Duke University Hospital. This guide provides a detailed, step-by-step approach to ensure that all necessary information is accurately submitted.

Follow the steps to successfully complete the Duke Referral Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's information. Provide the medical record number or social security number, date of birth, and full name. Be sure to also include the address, city, state, zip code, and contact numbers for home and work.
3. Indicate the scheduled test date and time, and the location of the appointment. This ensures that the planned procedure is recorded accurately.
4. List any known drug allergies. It is crucial to provide this information to ensure patient safety.
5. Fill in the primary care physician's details, including their name and phone number.
6. Provide the referring physician's information. Print the first name, middle initial, last name, and include their phone and fax numbers.
7. Ensure that the referring physician signs the form as their signature is required for services to be rendered.
8. If the patient is a child, fill in the required parent or guardian information including their name, mailing address, date of birth, social security number, employer and work phone number.
9. Select the appropriate study by placing an 'X' next to the desired examination such as CT, MRI, or Mammography. Also, provide the diagnosis or reason for the procedure.
10. Complete the insurance information section, including the insurance company name, address, phone number, and relevant policy and subscriber information.
11. If applicable, fill out the Medicare/Medicaid or Champus/HealthNet sections with the necessary identification and relationship information.
12. After reviewing all details for accuracy, you can save your changes, download the document, print it, or share the form as required.

Complete your Duke Referral Form online today to ensure a smooth scheduling process.