Follow the steps to successfully fill out the referral form.

1. Click ‘Get Form’ button to obtain the form and open it in the appropriate online editor.
2. Begin by entering the date at the top of the form. This helps in tracking the timeline of the referral process.
3. Fill in the patient information section. Provide the patient's name, address, daytime phone number, and alternate phone number. Be sure to select the patient’s gender by marking the appropriate box.
4. Input the patient's insurance information. It is essential to attach a copy of the insurance card as requested.
5. If the contact information differs from the patient’s details, complete the contact information section, including the name and phone number of the contact person.
6. In the referral information section, provide the name and phone number of the referring physician along with their fax number. Ensure you also include the scheduler's name.
7. State the reason for the referral or diagnosis in the designated space. Choose from options like urgent, second opinion, or routine, and indicate if there was previous radiotherapy by marking the appropriate box.
8. Don't forget to fax or email the most recent pertinent records, such as pathology reports and blood work, to support the referral.
9. Specify whether Dayton Physicians should contact the patient to notify the office when the appointment is scheduled by checking 'Yes' or 'No'.
10. If desired, provide additional information regarding Dayton Physicians Network by indicating 'Yes' or 'No'.
11. Finally, after completing the form, you can save changes, download, print, or share the form based on your needs.

Complete your referral forms online today for a more efficient process.