OUTPATIENT PHYSICIAN ORDER FORM - High Point Regional 2026

1. Click ‘Get Form’ to open the OUTPATIENT PHYSICIAN ORDER FORM in our editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, date of birth, phone number, gender, and social security number.
3. Next, complete the 'Insurance Information' section. Provide details for both primary and secondary insurance companies, including policy and group numbers.
4. In the 'Reason for Testing & ICD 9 CODE' section, clearly state the reason for the exam and include the required ICD 9 code. Avoid using vague terms like 'Rule out' or 'Assess'.
5. Select the appropriate exams from the list provided. Circle your choices and ensure you include any necessary CPT codes.
6. Finally, have the physician sign and date the form at the bottom. Ensure their name is printed clearly along with their office phone number.

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