Get Nc Port City Neurosurgery & Spine Referral Form 2018-2025

Filling out the NC Port City Neurosurgery & Spine Referral Form online is a straightforward process that helps facilitate patient referrals efficiently. This guide provides a step-by-step approach to assist you in completing the form accurately and effectively.

Follow the steps to complete the referral form online seamlessly.

1. Click the ‘Get Form’ button to acquire the referral form and open it in your preferred online editor.
2. In the section labeled ‘Referring Physician,’ enter your full name, NPI number, phone number, fax number, and direct mail address. Ensure this information is accurate to prevent any communication issues.
3. Provide the ‘Reason for Referral’ in the designated space. Be as specific as possible to help the specialists understand the patient's condition.
4. Specify when the patient needs the appointment by selecting ‘First Available’ or ‘ASAP’.
5. In the ‘Patient’ section, fill in the patient’s full name, including first name, middle/maiden name, last name, and suffix, if applicable.
6. Complete the patient’s street address, city, state, and zip code to ensure proper identification and communication.
7. Enter the patient’s date of birth, age, sex, marital status, and social security number accurately.
8. Provide the patient’s home phone number, work phone number, cell phone number, and email address to maintain contact with the patient.
9. In the ‘Primary Insurance’ section, enter the insurance company name, policy holder's name and date of birth, policy ID number, and group number.
10. Remember to include information regarding the date of injury. Note that if the insurance company is out of network, specific authorization requirements must be highlighted.
11. If applicable, complete the ‘Secondary Insurance’ section with corresponding insurance details.
12. Gather all required documents, including the insurance card copy, office notes, operative notes, and radiology reports. Ensure the patient brings all films to the appointment.
13. Finally, when all sections are completed and verified, you can save changes, download the form, print it, or share it as required.

Start filling out the referral form online today for a smooth referral process.