Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling out the Date field at the top of the form.
3. In the Referring Physician section, enter the name of the physician making the referral as well as their address and telephone information.
4. Complete the Fax number of the referring physician.
5. Fill in the Patient's Phone number, ensuring that it is accurate for communication purposes.
6. Provide the referring physician's address details, including City.
7. Enter the primary care physician’s (PCP) name and phone number along with their fax number.
8. Input the Case Manager's name, phone number, and fax number, if applicable.
9. Fill in the name and phone number of the PNO (Patient Navigation Office) involved.
10. Indicate the PNO address in the designated section.
11. Insert the Diagnosis and ICD-9 code relevant to the patient's condition.
12. Complete the Required Patient Information, including Last Name, First Name, Middle Initial, and Date of Birth.
13. Provide the patient’s phone number and indicate if the patient is Spanish speaking.
14. Fill in the patient’s complete address, city, state, and zip code.
15. Optionally enter the patient's Social Security number.
16. Select the Insurance Plan, ensuring it reflects the correct coverage.
17. Finally, fill out the Form Completed By section with your name and phone number.
18. Review the completed form for any errors before saving, downloading, printing, or sharing the document.

Take the next step and complete your Magellan EKG Referral Request Form online today.