Fax Referral Form - Pacific Infusion Center 2026

1. Click ‘Get Form’ to open the Fax Referral Form in the editor.
2. 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.
3. 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#.
4. Next, specify the Diagnosis and corresponding ICD-9# codes based on the patient's condition. Refer to the provided options for accurate coding.
5. Indicate whether the patient has a calculated creatinine clearance of ≥ 35mL/min and a normal serum calcium level by selecting 'Yes' or 'No'.
6. Complete the Insurance Information section with details about primary and secondary insurance providers, including phone numbers and policy numbers.
7. Attach any required documents such as lab results and prescriptions before signing at the bottom of the form.
8. Finally, ensure to fax back infusion confirmation details after filling out all necessary fields.

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