Ohio State University Physician Referral Form
The Ohio State University Wexner Medical Center's Physician Referral Form is designed for healthcare providers to efficiently refer patients. This form includes all necessary patient and provider information for processing referrals. Please ensure that all clinical documentation is included to avoid delays.
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How do I fill this out?
To fill out the Physician Referral Form, start by providing complete and accurate patient information. Next, enter the referring provider's details, ensuring all required fields are filled. Finally, review the form for completeness before submitting it via fax.
How to fill out the Ohio State University Physician Referral Form?
1
Complete the patient information section.
2
Fill in the details of the referring provider.
3
Include any relevant clinical documentation.
4
Check all entries for accuracy.
5
Submit the completed form via fax to the designated number.
Who needs the Ohio State University Physician Referral Form?
1
Primary care physicians who need to refer patients to specialists.
2
Patients requiring urgent medical attention through physician referrals.
3
Healthcare administrators handling patient scheduling and coordination.
4
Insurance representatives verifying referral requests.
5
Specialists requiring patient information to prepare for new consultations.
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1
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What are the instructions for submitting this form?
To submit the Physician Referral Form, ensure that all sections are filled out completely with accurate information. Fax the completed form along with any clinical documentation to 614-293-1456. For urgent referrals, you can call 614-293-5123 to discuss the case directly with a scheduling representative.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, there are no specific important dates associated with this form. It remains applicable year-round for patient referral needs. Make sure to keep up with any updates from the Ohio State University Wexner Medical Center regarding referral processes.
What is the purpose of this form?
The main purpose of the Ohio State University Physician Referral Form is to facilitate clear communication between healthcare providers when referring patients for specialized care. This form ensures that all pertinent patient information is collected in a standardized manner, minimizing the potential for errors. By streamlining the referral process, both patients and providers benefit from improved coordination and expedited care.
Tell me about this form and its components and fields line-by-line.
- 1. First Name: Patient's first name for identification.
- 2. Middle Name: Optional field for the patient's middle name.
- 3. Last Name: Patient's last name.
- 4. Gender: Patient's gender for demographic information.
- 5. Marital Status: Patient's marital status.
- 6. Last 4 digits of SSN: Last four digits of the patient's Social Security Number.
- 7. Date of Birth: Patient's date of birth in mm/dd/yyyy format.
- 8. Primary Phone: Contact number for the patient.
- 9. Street Address: Patient's residential address.
- 10. City: City of residence.
- 11. State: State of residence.
- 12. Zip: Postal zip code.
- 13. Country: Country of residence.
- 14. Reasons for Referral: Reason for referring the patient.
- 15. Preferred Physician: Name of the preferred physician for the referral.
- 16. NPI Number: National Provider Identifier for the referring provider.
- 17. Provider Title: Title of the referring provider.
What happens if I fail to submit this form?
Failure to submit the Physician Referral Form can result in delays in patient care. Important clinical information may be disregarded, potentially affecting treatment timelines. It is crucial to submit all required documentation to avoid these issues.
- Delays in Patient Care: Without the form, patients may experience delays in receiving needed consultations.
- Incomplete Patient Information: Missing details may prevent providers from understanding patient needs.
- Insurance Issues: Insurance verification may be adversely affected without the proper referral documentation.
How do I know when to use this form?
- 1. Referral to a Specialist: When a patient requires specialized medical attention.
- 2. Second Opinion Requests: For patients seeking additional insights on their medical condition.
- 3. Transfer of Care: When transitioning a patient's care to another provider.
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