Get Referring Doctor's Name: - Med Unc

Filling out the Referring Doctor's Name: - Med Unc form is a crucial step in scheduling an appointment with the UNC Gastroenterology Specialty Clinics. This guide will provide you with clear and supportive instructions to ensure you successfully complete the form.

Follow the steps to accurately complete the referral form.

1. Begin by clicking the ‘Get Form’ button to access the form. This will allow you to open the document in an editable format.
2. Once the form is open, locate the section titled 'Patient Information'. Fill out the patient’s demographics, including their last name, first name, and date of birth.
3. In the 'Patient Information' section, provide the primary and alternate phone numbers along with the patient’s street address, city, state, and ZIP code.
4. Next, check all applicable symptoms from the list provided, including but not limited to conditions like reflux, chronic constipation, or any other listed conditions relevant to the patient.
5. Move to the section labeled 'Referring Physician Information'. Here, enter the referring physician's name, practice name, street address, phone number, city, state, ZIP code, fax number, and email address.
6. If applicable, check the box indicating whether the referring physician is also the primary care physician.
7. Proceed to fill out the 'Insurance Policy Holder Information'. Indicate the relationship of the policyholder to the patient, along with the policyholder’s name, date of birth, primary insurance carrier, policy number, and group number.
8. Lastly, confirm any secondary insurance coverage by providing the necessary details, including the secondary insurance carrier and effective date.
9. Once all sections are completed, review the form for accuracy. Afterwards, you can save your changes, download, print, or share the completed form as needed.

Complete your referral form online today to ensure timely processing and appointment scheduling!