General Nutrition Counseling Referral Form PDF - Yale-New Haven - ynhh 2026

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Click ‘Get Form’ to open it in the editor.
Begin by entering the required patient information, including the patient's name, MRN, EPIC number, date of birth, address, and best daytime phone number. Ensure all fields are filled accurately for effective processing.
Specify the type of diet instruction needed and list any medications the patient is currently taking. This information is crucial for tailoring the nutrition plan.
Check all applicable reasons for referral and provide additional diagnoses with ICD-9 codes as necessary. Remember that a diagnosis code is mandatory before scheduling appointments.
Complete the physician information section by filling in your name, address, phone number, fax number, and signature. This validates the referral.
Once completed, save your changes and fax the form along with any relevant clinical information to ensure a smooth referral process.

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