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01. Edit your ucsf referral form online
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How to use or fill out medical referral form with our platform
- Click ‘Get Form’ to open the medical referral form in the editor.
- Begin by entering the date and your contact information in the 'From' section, including your title, phone number, and fax number.
- Fill in the 'Patient Information' section with the patient's name, date of birth, and contact numbers. Ensure you include a parent or caregiver's details if applicable.
- In the 'Consultation Request Information' section, provide a diagnosis code (ICD-9/10), specify the UCSF MD if known, and detail the reason for consultation.
- Complete the 'Referring Physician Information' by entering your name, specialty, phone number, and fax number. Don't forget to sign at the bottom to authorize treatment initiation.
- Review all entered information for accuracy before submitting. You can easily save or print your completed form directly from our platform.
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