FIBROSCAN ORDER FORM - The Queens Medical Center - queensmedicalcenter 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the patient’s name and date of birth in the designated fields. Ensure accuracy as this information is crucial for scheduling.
3. Complete the address section, including city, state, and zip code. This helps in identifying the patient's location for any necessary follow-ups.
4. Provide the social security number and contact numbers (home and other) to facilitate communication regarding the referral.
5. Attach a copy of the medical insurance card (front & back) and fill out both primary and secondary insurance details.
6. Indicate if an interpreter is needed by checking 'Yes' or 'No'. If yes, ensure arrangements are made as per instructions.
7. Select the reason for referral by checking one of the options provided. This assists in prioritizing patient care effectively.
8. Finally, have the referring physician sign and date the form before submission to ensure all required authorizations are complete.

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