Fax Completed Form to: (910) 321-6253 - Cape Fear Valley Health ...-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting the physician you are referring to from the provided list. This ensures that your referral is directed correctly.
3. Fill in the 'Reason for Referral/Consult' section, providing a clear explanation of why the patient is being referred.
4. Complete the 'Patient Information' section, including full name, date of birth, and contact details. Accurate information here is crucial for effective communication.
5. In the 'Physician Information' section, enter your details as the referring physician, including office phone and address.
6. Provide insurance information and any necessary authorization numbers if applicable. This will facilitate billing and coverage processes.
7. Ensure you sign in the designated area without using a stamp, and include the date of signing.
8. Review all entered information for accuracy before finalizing your document.
9. Once completed, use our platform's fax feature to send the form directly to (910) 321-6253.

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