Get Ipi-consultation-request-form-new-updated-05.24.11.doc - Inova

Filling out the IPI Consultation Request form is a crucial step in ensuring that the necessary consultations are arranged efficiently. This guide provides clear and supportive instructions for completing the form online, making the process straightforward for all users.

Follow the steps to efficiently complete the IPI consultation request form.

1. Click the ‘Get Form’ button to obtain the consultation request form and open it in your preferred document editor.
2. In the Patient Information section, fill in all required fields marked with an asterisk (*). Enter the patient's last name, first name, middle name (if applicable), and complete the street address, city, state, ZIP code, and country fields. Ensure to provide the phone number and date of birth in the specified format (MM/DD/YY).
3. Select the patient's sex by marking either 'M' for male or 'F' for female in the respective field. If needed, reference the instructions regarding sex designation within the document.
4. Complete the Social Security number and race fields if required. Ensure that you have the necessary information on hand to provide accurate details.
5. Next, you need to sign the form in the Signature Required section. This signature indicates agreement to the terms outlined in the letter of understanding if applicable.
6. For the contributors, fill in the contributor's last name, first name, fax number, email, and phone number in the respective fields. If the contributor is located outside the U.S., it is advised to call for guidance on submission.
7. In the Contributor’s Working Diagnosis section, fill in the ICD-9 code(s) where applicable. Make sure to include all relevant materials being forwarded as listed, marking each item that is included.
8. Provide a detailed clinical history, including key information such as location, size, duration, symptoms, and any findings from physical and laboratory tests. This section is vital for context in the consultation.
9. Complete any additional comments and special requests that may be relevant to the consultation. This can help further clarify concerns or unique requirements.
10. After all sections are completed, review the document for accuracy. You can then save changes, download, print, or share the form as necessary.

Start filling out the IPI consultation request form online today to ensure prompt processing of your request.