Get Ne Chi Health Clinic Endocrinology Referral Request Form

Filling out the NE CHI Health Clinic Endocrinology Referral Request Form online is an essential process for ensuring that patients receive the appropriate care. This guide will provide you with step-by-step instructions to complete the form effectively and efficiently.

Follow the steps to complete the referral request form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, enter the name of the patient in the designated field. Ensure that you provide the full name for clarity.
3. Next, fill in the date of birth of the patient. Use the format specified in the form to avoid delays.
4. Provide the patient's phone number or contact information. This is essential for any follow-up communication regarding the referral.
5. In the 'Reason for Referral' section, clearly state the medical reason for the referral. Be specific to ensure the endocrinology team has the necessary information.
6. Identify the referring provider by entering their name in the appropriate field. This helps in tracking the referral accurately.
7. Include the referring provider’s fax number to facilitate the sending of necessary documents to the clinic.
8. Gather the required documents to be faxed to the clinic at 402-875-7208, including the completed referral form, office notes from the last year, lab results, diagnostic testing, current medication list, demographic information, and copies of insurance cards.
9. Once all sections are completed, save your changes in the form. You then have the option to download, print, or share the form with the necessary parties.

Complete your referral request form online today to ensure timely patient care.