Get Oh The Metrohealth System External Physician Referral Form 2021-2025

Filling out the OH The MetroHealth System External Physician Referral Form online is a straightforward process that allows healthcare providers to refer patients efficiently. This guide provides clear, step-by-step instructions to help you complete the form accurately and effectively.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date at the top of the form. This helps to keep records up to date.
3. Provide the printed attending provider's name in the designated field, including both first and last names.
4. Fill in the National Provider Identifier (NPI) number in the specified space, ensuring accuracy for proper identification.
5. Sign the form in the 'Provider's Signature' area, confirming the referral.
6. Next, enter the referring provider's phone and fax numbers in the respective fields to facilitate communication.
7. Complete the facility address and zip code to indicate where the referral originates.
8. Input the patient's full name in the designated space. Ensure spelling is correct.
9. Provide the patient’s Social Security number in the appropriate field for identification purposes.
10. Enter the patient’s phone number and birthday, ensuring accurate contact details.
11. Complete the patient’s address, ensuring it is current and complete for any follow-up communication.
12. Fill in the insurance company details, including the ID number and group number, to facilitate billing.
13. Specify the requested specialty department or procedure, indicating whether a radiology test is required with or without contrast.
14. If applicable, indicate the specific specialty physician you are requesting.
15. Detail the diagnosis, reason for referral, and associated ICD code in the provided section to communicate the medical necessity.
16. Attach a progress note that includes subjective and objective indications for the requested test.
17. If necessary, include any prior approval letters from the insurance company in the submission.
18. Make copies of the form for future referral requests as required.
19. Once completed, save any changes made, and opt to download, print, or share the form as needed.

Complete and submit your documents online to ensure a smooth referral process.