Get Tx Medical Advisory Board (mab) Physician Referral Form 2021-2025

Filling out the TX Medical Advisory Board (MAB) Physician Referral Form online is a straightforward process. This guide will help you navigate each section of the form effectively, ensuring that all required information is provided clearly and accurately.

Follow the steps to complete the Physician Referral Form online

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. In the 'Patient and Physician Information' section, begin by entering the patient's last name, first name, and middle initial in the designated fields.
3. Next, input the patient's address, including the city, state, and ZIP code, ensuring all information is accurate for communication purposes.
4. Provide the patient's date of birth in the specified format, to assist in identifying the patient correctly.
5. If known, enter the patient's driver license number, which may help in processing the referral efficiently.
6. Include the patient’s Social Security number in the corresponding field for identification and record-keeping.
7. In the section regarding medical limitations, clearly explain any specific medical conditions that may affect the patient's ability to drive. This is crucial for the advisory board's assessment.
8. After completing the patient information, sign the form in the designated area to certify the accuracy of the information provided.
9. Print your name and provide your Texas physician license number, ensuring all credentials are visible and legible.
10. Lastly, input your telephone number and address, including city and ZIP code, in the respective fields to facilitate follow-up communication if necessary.
11. Once all fields are filled out accurately, save your changes, download the form, print it if necessary, or share it as required.

Get started on your Physician Referral Form today to support patient safety and compliance.