Get Ne Chi Health Clinic Endocrinology Referral Request Form 2021-2025

Filling out the NE CHI Health Clinic Endocrinology Referral Request Form online is a straightforward process that ensures efficient communication between referring providers and the clinic. This guide breaks down each section of the form to assist you in submitting an accurate and complete request.

Follow the steps to successfully complete the referral request form.

1. Press the ‘Get Form’ button to access the NE CHI Health Clinic Endocrinology Referral Request Form and open it for editing.
2. Enter the patient's name in the designated field marked 'Name of Patient'. Ensure the name is spelled correctly and is easily verifiable.
3. Fill in the patient's date of birth in the 'Date of Birth' field. This information is crucial for identifying the patient.
4. Provide a contact number for the patient in the 'Patient Phone Number/Contact Information' section. This will be used for any necessary communication regarding the referral.
5. Clearly articulate the reason for the referral in the 'Reason for Referral?' space. Be as detailed as possible to facilitate the scheduling process.
6. Complete the 'Referring Provider?' section by entering the name of the practitioner making the referral. This informs the clinic who to contact for further information if needed.
7. Input the referring provider's fax number in the 'Referring Provider’s Fax Number?' field. This is necessary for sending additional documentation.
8. Attach the required documents by ensuring they are ready to be faxed to 402-875-7208. These include the completed referral form, office notes from the last year, labs from the last year, diagnostic testing results, the current medication list, and demographic information along with insurance cards.
9. Once all fields are filled and documents prepared, review the form for accuracy. Save your changes, and proceed to download, print, or share the referral form as needed.

Complete and submit your referral request form online to ensure a prompt review and scheduling of your patient’s initial visit.