Get Queen's Medical Center Consultation Request Form 2018-2025

Completing the Queen's Medical Center Consultation Request Form online is an essential step in scheduling a medical consultation. This guide provides clear, detailed instructions to help you fill out the form accurately and efficiently.

Follow the steps to successfully complete the consultation request form.

1. Click ‘Get Form’ button to access the consultation request form and open it for editing.
2. Begin by filling in the patient information section. Include today's date, the patient's full name, date of birth, current address, and email address. If the mailing address is different from the current address, fill in that section as well. Please ensure you provide both primary and secondary phone numbers.
3. Indicate the patient's primary language from the options provided and provide the name of the referring physician. If applicable, also fill in the fax number and the phone number of the referring physician.
4. For the question regarding the patient's ability to ambulate, select either 'YES' or 'NO'.
5. Next, provide health insurance information. Fill out the primary and secondary insurance details, including the subscriber's name and subscriber ID for each.
6. Indicate whether authorization is required by selecting 'YES' or 'NO'. If authorization is required, remember to provide the authorization number.
7. Choose the reason for the referral request from the options listed. You may select 'Next Available', 'ASAP', 'Screening', 'Follow-Up', or specify another reason.
8. Include the appropriate ICD-10 diagnosis for the patient's condition and provide any special instructions pertinent to the referral.
9. The ordering physician must certify the necessity of the procedure by signing in the designated area.
10. Select the requested provider from the list of physicians available and fill in the date next to the selected provider.
11. Review the form for completeness. Ensure that all fields are filled and all necessary documentation is ready to be faxed along with the request form.
12. Once everything is double-checked, save changes, download the completed form, print it out, or share it according to your needs.

Complete the Queen's Medical Center Consultation Request Form online today to ensure timely processing of your request.