Cast Clinic Referral Form - Dell Childrens Medical Center of Central 2026

1. Click ‘Get Form’ to open the Cast Clinic Referral Form in the editor.
2. Begin by filling in the 'FROM' section with your name, phone number, and fax number. This information is crucial for communication.
3. Complete the patient details: enter the patient's name, date of birth (DOB), and contact information including their address.
4. In the 'Referring Physician' section, provide the full name and credentials (M.D. or D.O.) of the referring physician. If there is a different primary care physician, include their details as well.
5. Specify the diagnosis and include relevant CPT or ICD9 codes. Clearly state the reason for referral and select the appropriate insurance type (HMO or PPO).
6. Fill out any additional required fields such as DOI, mechanism of injury, and whether films are available. Ensure all sections are completed to avoid rejection.
7. Finally, have the referring physician sign and date at the bottom of the form before submitting it via fax to ensure proper processing.

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