Follow the steps to easily complete your online referral form.

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 date helps in organizing referrals properly.
3. Fill in the patient information section, which includes the last name, first name, middle initial, and birth date of the patient. Ensure the information is accurate for identification purposes.
4. Provide the patient's gender by selecting 'Male' or 'Female' and enter their Social Security number for insurance purposes.
5. Complete the address section, which requires the street address, city, state, and zip code to locate the patient.
6. In the reason for referral section, select the appropriate options that describe the referral type, such as referral for treatment or consultation.
7. Indicate any completed treatments by checking relevant boxes, including behavior management or second opinion.
8. Add the insurance information by selecting whether the patient has private insurance or participates in OHP or Washington programs. Ensure you enter the Card ID number if applicable.
9. If there are special requests such as needing an interpreter, indicate the preferred language in the designated area.
10. Fill in the referring dentist's information, including their name, address, and telephone number for follow-up.
11. Once all information is completed, review the form for accuracy. After confirming that all details are correct, you can save changes, download, print, or share the form as necessary.

Complete the online OR OHSU Pediatric Patient Referral Form now for a seamless referral process.