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Get Cpmc Referral Form
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How to fill out the Cpmc Referral Form online
Completing the Cpmc Referral Form online can streamline the referral process for your patient. This guide offers you a concise overview and step-by-step instructions on filling out the form to ensure that you provide all necessary information accurately.
Follow the steps to complete the Cpmc Referral Form effectively.
- Click ‘Get Form’ button to obtain the form and open it for editing.
- Provide the referring physician's information. Fill in the name, contact person, address, and both phone and fax numbers in the designated fields.
- Enter the patient information section. Input the patient's name, date of birth, insured's name, social security number, and phone numbers for home and work.
- Complete the patient's address, including street address, city, state, and zip code. Ensure that the information is accurate.
- In the diagnosis section, specify the diagnosis and include the relevant ICD-9 code.
- Provide the reason for the referral as well as the history and physical examination details in the respective field.
- Indicate the specialty and/or physician requested for the referral.
- Fill in the insurance information. Attach a copy of the insurance card and complete the health plan, product type, medical group, authorization number, number of visits, effective dates, and identification number.
- List the services authorized. For consultations, make sure to use CPT code 99244, and for follow-ups, use CPT code 99214.
- Review the checklist to ensure all required documents are included, such as the patient information sheet, copies of insurance cards, and pertinent medical records.
- Once all sections are completed, you can save your changes, download, print, or share the form as necessary.
Complete the Cpmc Referral Form online to facilitate timely patient referrals.
Writing a referral involves drafting a clear and concise document that states the main purpose of the transfer of care. Include key details like the patient's information, the referring provider’s insights, and the recommended specialist. Using a template like the Cpmc Referral Form from USLegalForms can simplify this task by providing structured guidance to ensure nothing is overlooked.
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