Get Queen's Medical Center Provider Referral Request Form 2015-2025

Completing the Queen's Medical Center Provider Referral Request Form online is a straightforward process that ensures your referral is handled efficiently. This guide provides detailed guidance on each section of the form to support users in filling it out correctly.

Follow the steps to fill out the referral request form accurately.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Select the relevant specialty from the provided options. If your specialty is not listed, use the 'Other' field to specify your needs.
3. Input the referring provider’s name and affix their signature in the designated areas, ensuring that contact information, including phone and fax numbers, is accurate.
4. Indicate if the appointment is urgent or routine, and if routine, specify if you wish to see a specific physician.
5. Provide the patient’s full legal name, date of birth, and phone number, along with their email address.
6. If the patient is a minor, include the parent or guardian's contact information.
7. Articulate the reason for the referral in the clinical question section. Provide detailed comments and include relevant medical information such as recent labs and imaging reports.
8. Specify if the patient is aware of the referral reason and whether interpreter services are required, filling in the necessary fields.
9. Complete the physician's information, including their name, National Provider Identifier (NPI), signature, phone number, and fax number.
10. Gather any necessary documentation such as patient contact information, prior authorizations, and office visit notes, and ensure they are ready to be faxed along with the form.
11. Once all sections are filled, review the form for accuracy and completeness. Users can save changes, download, print, or share the completed form as needed.

Start filling out the Queen's Medical Center Provider Referral Request Form online today for a smooth referral process.