Get Oh Dayton Physicians Network Referral Form Urology 2018-2025

Completing the OH Dayton Physicians Network Referral Form Urology online is a straightforward process that ensures proper communication of patient information. This guide will walk you through each section of the form step-by-step, making the completion process efficient and clear.

Follow the steps to successfully fill out your referral form.

1. Press the ‘Get Form’ button to access the referral form and open it in your preferred online tool.
2. Enter the date at the top of the form. This is important for record-keeping purposes.
3. In the patient information section, provide the patient's name. Indicate their gender by selecting the appropriate checkbox.
4. Next, complete the patient's address, including city, state, and zip code, along with both daytime and alternate phone numbers.
5. Fill in the patient's date of birth and the last four digits of their Social Security number to help identify the patient.
6. Specify the language spoken by the patient and indicate whether they are hearing impaired.
7. List the patient's insurance details and ensure to send a copy of their insurance card with the form.
8. If contact information differs from the patient’s, provide the name and phone number of the contact person.
9. In the referral information section, enter the referring physician's name, phone number, and fax number, along with the scheduler's name.
10. Describe the reason for referral or diagnosis in the provided space, checking any applicable options such as second opinion or urgent.
11. Indicate whether to fax or email the most relevant patient records, such as pathology reports, radiology reports, blood work, and progress notes.
12. State whether Dayton Physicians will contact the patient regarding the scheduling of an appointment.
13. Provide additional information about the Dayton Physicians Network if required.
14. For office use, document the appointment date, time, physician, and location as needed.
15. Once completed, you can save changes, download, print, or share the form as necessary.

Complete your referral form online today to ensure prompt and efficient processing.