UPMC Western MarylandHome 2026

1. Click ‘Get Form’ to open the UPMC Western MarylandHome in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the primary care provider's name, patient’s address, and phone number. This helps maintain clear communication regarding the patient's care.
4. Attach a copy of the health insurance card as instructed. This is essential for processing referrals and verifying coverage.
5. Indicate the services for which the patient is being referred by checking the appropriate boxes. Be sure to provide any necessary supporting test results.
6. Complete all sections related to diabetes diagnosis and current treatment, selecting from provided options to ensure comprehensive information is captured.
7. If applicable, circle any special needs requiring accommodations. This ensures that all patient requirements are addressed during their care.
8. Finally, have the referring provider print and sign their name before faxing the completed form to the specified number.

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