Referral Fax Form - Baystate Health 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, middle initial, street address, city, state, date of birth (DOB), phone number, social security number (SSN), sex, race, marital status, language preference, and indicate if the patient lives alone or if their information is in CIS.
3. Next, complete the 'Insurance Information' section. Provide details for Medicare and Medicaid numbers along with the insurance company name and policy number.
4. In the 'Referrer' section, input the name of the office contact who is referring the patient.
5. Proceed to specify 'Home Care Services Requested.' Check appropriate boxes for diabetes management or cardiovascular disorders and provide necessary details such as current glucose levels or weight.
6. Fill out any additional sections related to medications/diet changes and reason for home care. Ensure to list allergies and medications clearly.
7. Finally, review all entered information for accuracy before submitting your completed form via fax at (413) 794-6475.

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