Edit, Download, and Sign the Infusion Referral Form for Integrated Health Clinic
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How do I fill this out?
To fill out this form, start by completing patient identification details at the top. Next, include relevant medical information and any allergies. Finally, ensure that a physician's signature is provided before submission.
How to fill out the Infusion Referral Form for Integrated Health Clinic?
1
Complete the patient identification section.
2
Fill in the relevant medical details and history.
3
Indicate any allergies or previous infusion reactions.
4
Choose the required infusion orders from the options.
5
Have the physician sign and date the form.
Who needs the Infusion Referral Form for Integrated Health Clinic?
1
Patients with iron deficiency needing treatment.
2
Physicians who refer patients for infusions.
3
Healthcare providers managing infusion therapy.
4
Insurance companies for verification of procedures.
5
Administrative staff for scheduling and billing purposes.
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1
Open the PDF in PrintFriendly.
2
Click on the section you want to edit.
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What are the instructions for submitting this form?
Submit the completed form via fax to 604-888-8365 or email it to admin@integratedhealthclinic.com. You can also visit the clinic at 23243 Mavis Ave, Fort Langley BC, or 13585 16 Avenue, Surrey BC for in-person submission. It's advised to keep a copy for your records.
What are the important dates for this form in 2024 and 2025?
Please check with Integrated Health Clinic for specific dates regarding your infusion treatments in 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to facilitate the referral process for patients requiring iron infusion therapy. It ensures that all necessary medical information is provided to effectively manage treatment. This form also helps streamline communication between the patient, physician, and healthcare facility.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Identification: Includes the patient's name, PHN, and date of birth.
- 2. Medical Details: Information regarding the patient's medical history related to iron deficiency.
- 3. Allergies: Details of any known allergies or previous infusion reactions.
- 4. Infusion Orders: Specifies the type of iron infusion required.
- 5. Physician's Signature: Mandatory signature from the referring physician.
What happens if I fail to submit this form?
Failure to submit this form may delay the scheduling of your infusion therapy. It can result in missed treatment opportunities and complications related to iron deficiency. Ensure all information is accurately filled out and submit it promptly to avoid disruptions.
- Delayed Treatment: Not submitting on time may postpone necessary iron infusion therapy.
- Incomplete Information: Missing details could lead to rescheduling or denial of treatment.
- Insurance Issues: Incomplete forms may affect insurance coverage and claims.
How do I know when to use this form?
- 1. Iron Deficiency Diagnosis: Patients diagnosed with iron deficiency should use this form for referral.
- 2. Infusion Scheduling: Required for scheduling appointments at the clinic.
- 3. Insurance Verification: Provides necessary medical details for insurance purposes.
Frequently Asked Questions
What is the purpose of this form?
This form serves as a referral for iron infusion treatment.
How do I submit the completed form?
You can submit it via fax or email to Integrated Health Clinic.
Can I edit this form online?
Yes, PrintFriendly allows you to edit the PDF online.
Is a physician's signature necessary?
Yes, a physician’s signature is required for the referral.
How do I know if I need this form?
If you are experiencing iron deficiency and need treatment, this form is necessary.
Can I share this document with others?
Yes, you can share the PDF easily through PrintFriendly.
What information is required on the form?
You will need to provide patient details, medical history, and infusion orders.
How much does the infusion cost?
IHC charges a $235 infusion fee per session.
What if there are errors in the form?
You can easily edit the form to correct any errors before submission.
Who should fill out this form?
Patients should fill this out, ideally with assistance from their healthcare provider.
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