Uniform Consultation Referral Form - Wikiform 2025

1. Click ‘Get Form’ to open the Uniform Consultation Referral Form in the editor.
2. Begin by entering the 'Date of Referral' at the top of the form. This is essential for tracking purposes.
3. In the 'Carrier Information' section, fill in the name of the insurance carrier responsible for the patient’s coverage.
4. Next, complete the 'Patient Information' fields. Include the patient's full name, date of birth, phone number, member number, site number, and address.
5. Proceed to enter details for both the 'Primary or Requesting Provider' and 'Consultant/Facility Provider'. Ensure you include names, institutions/groups, addresses, phone numbers, specialties, and provider IDs.
6. In the 'Referral Information' section, specify the reason for referral and provide a brief history including diagnosis and test results. Be sure to include any relevant ICD-9 codes.
7. Indicate services desired and select a place of service from the options provided. Fill in any additional details as necessary.
8. Finally, sign where indicated and obtain an authorizing signature if required before submitting your completed form.

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