Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the document and open it in the editor where you can begin filling out the required information.
2. Start with the patient demographic information. Enter the date, patient name, address (including city, state, and zip), social security number, date of birth, home phone, work phone, cell phone, and email address. Also, add the emergency contact name and phone number, as well as gender and race.
3. Next, provide the referring physician information. Fill in the physician's name, group name (if applicable), address (including city, state, and zip), office phone, fax, and email address. Include the name of the person completing the form.
4. Input patient insurance information. Enter the insurance name, policyholder's name and date of birth, policy number, insurance phone, and group number. If there is secondary insurance, repeat the same entries as in the previous step.
5. Provide patient general clinical information if available. Add the Duke history number, patient height, smoking cessation date, patient weight, and oxygen use details at rest and during exertion.
6. Complete the required medical information section by checking the box next to each document that you will attach. This includes arterial blood gas results, recent chest x-ray report, clinic notes with current medications, operative reports from thoracic surgeries, cardiology study reports, and recent lab results.
7. After all sections are filled out, review the information for accuracy and completeness before submitting. You can then save changes, download, print, or share the completed form as needed.

Start completing your DukeMedicine MCOC-9426 online today for seamless patient referral.