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1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the date at the top of the form. This is essential for tracking the referral process.
3. Fill in the patient's name, birth date, and social security number. Ensure accuracy as this information is critical for identification.
4. Complete the patient's address details including state, city, and zip code. This helps in locating the patient for follow-up.
5. Provide contact numbers for home, cell, and work to facilitate communication regarding the patient's admission.
6. In the 'Reason for Consult' section, clearly state why the patient is being referred. This aids in prioritizing care.
7. The referring physician must sign and provide their contact information. This validates the referral and ensures accountability.
8. Indicate current location of the patient and any relevant medical conditions by checking appropriate boxes and noting dates of onset.
9. Finally, attach copies of insurance cards as required before submitting via fax to ensure coverage during admission.

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