Fax Referral Form - Pacific Infusion Center 2025

See details

4 out of 5

29 votes

The document is a Fax Referral Form for referring a patient to an infusion center for a Reclast infusion. It includes sections for the referring physician's information, patient details, diagnosis codes related to osteoporosis and fractures, insurance information, and necessary lab results. The form emphasizes the importance of calcium and vitamin D supplementation and provides safety information regarding Reclast.

Here's how it works

01. Edit your reclast infusion online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send reclast via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out Fax Referral Form - Pacific Infusion Center with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the Fax Referral Form in the editor.
Begin by entering the Referring Physician’s Name, Phone, and Fax number at the top of the form. This information is crucial for communication regarding your patient.
In the Patient Information section, fill in the Patient Name, SS#, Address, Phone, and Date of Birth. Ensure you have patient permission before including their SS#.
Next, specify the Diagnosis and corresponding ICD-9# codes based on the patient's condition. Refer to the provided options for accurate coding.
Indicate whether the patient has a calculated creatinine clearance of ≥ 35mL/min and a normal serum calcium level by selecting 'Yes' or 'No'.
Complete the Insurance Information section with details about primary and secondary insurance providers, including phone numbers and policy numbers.
Attach any required documents such as lab results and prescriptions before signing at the bottom of the form.
Finally, ensure to fax back infusion confirmation details after filling out all necessary fields.

Start using our platform today to streamline your document editing and form completion process for free!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the best way to send my Fax Referral Form - Pacific Infusion Center for eSignature?

Upload your Fax Referral Form - Pacific Infusion Center to DocHub (once you’ve created an account for this). If you need to complete fields in it, use appropriate tools from the top pane. For instance, add Signature Fields, assign each to a particular person, and click on Sign → Request signatures from others. Personalize your message for your recipients and click Send Request. You can also send your document by fax or as a Signing link instead of using email (you’ll find these options by navigating to the Menu → Send)

Do I need to set up software to edit my Fax Referral Form - Pacific Infusion Center?

When you edit your Fax Referral Form - Pacific Infusion Center with DocHub, you only require a steady internet connection and virtually any web browser installed on your device. No need to install any third-party applications or study tutorials. Just open a tab with DocHub, drag and drop your file, and modify it on the spot.

What is an example of referring a patient?

I am referring [patients name], a [Age] year old [male/female], for evaluation of their [presenting problem]. These reported concerns have been occurring for the past [X] months/years. I have been [patients name]s primary care physician/specialist for the past [X] years.

How to fill a patient referral form?

How to Write a Medical Referral Letter with Examples Header with Practice Details and Date. Recipients Information and Greeting. Patient Identification and Reason for Referral. Clinical Details. Investigations and Test Results. Reason for Referral and Request for Action. Patient Contact Information and Enclosures.

How do you write a referral example?

[Colleagues Name] and I have known each other for [length of time] and I have been impressed with their skills and work ethic and believe they would be a great fit at [Company Name]. [Colleagues Name] has [relevant skills and experience] that make them an ideal candidate for the role.

Is an infusion center a clinic?

An infusion center is an outpatient clinic certified to administer treatment intravenously.

How to fill out a referral form?

What should a referral form include? A referral form should include the name and contact information of the person making the referral, the name and contact information of the person or business being referred, and any relevant details about the referral. 5. Can referral forms be customized?

Fax Referral Form - Pacific Infusion Center 2025

Here's how it works