Medical referral form 2026

1. Click ‘Get Form’ to open the medical referral form in the editor.
2. Begin by filling out the 'Referring Physician' section. Enter your name, specialty, address, phone number, and fax number. Don’t forget to sign and date the form.
3. Next, move to the 'Patient Information' section. Input the patient's name, Social Security Number (SSN), date of birth (DOB), address, and contact numbers. If the patient is a child, include the parent's name.
4. In the 'Referring Indication' section, specify the reason for consultation and provide a diagnosis code (ICD9). Include details about the primary care provider along with their address and phone number.
5. Ensure you have all necessary documents ready for submission: a copy of the patient’s insurance card (front and back), authorization from HMO plan or CCS if applicable, and pertinent medical records.

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