Get Atrium Health Center For Liver And Digestive Disease: Referral Form 2019-2025

Filling out the Atrium Health Center For Liver And Digestive Disease: Referral Form online is an essential process for ensuring that patients receive timely and effective care. This guide will provide clear instructions to help you complete the form accurately and efficiently.

Follow the steps to successfully complete the referral form.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by entering the date in the designated field. This helps to keep track of when the form is completed.
3. Complete the 'Patient Information' section. Start with marital status and then indicate the patient's gender by selecting either male or female. Provide the patient's race, date of birth, and social security number.
4. Fill in the address section with the patient's street address, city, state, and zip code. Don't forget to include the email address and phone numbers for home, cell, and work.
5. In the 'Emergency Contact' section, write down the name of the emergency contact and their relationship to the patient. Provide their home and cell phone numbers as well.
6. Move to the 'Insurance Information' part of the form. Enter details for the primary care physician, including their phone number and fax number. Fill in the primary insurance company, policy number, and group number.
7. If applicable, provide information about the subscriber if they are not the patient, as well as their date of birth and NPI number.
8. Next, in the 'Practice Information' section, input the referring provider's name and the reason for referral. Also, fill in the name of the practice and the office contact.
9. Complete the address for the practice with street, city, state, and zip. Lastly, provide contact information including phone and fax numbers.
10. Specify the services being requested from the available options, such as transplant referral or recent labs.
11. Ensure to send a copy of the patient's insurance card along with the completed form. For Medicaid plans, include the NPI number and authorization.
12. Once all sections are complete, save your changes to the form. You may also choose to download, print, or share the completed form as needed.

Start filling out the referral form online today to ensure timely care for your patients.