SMH4092 Center for Women & Infants Fibroid Center Referral.indd 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name, Date of Birth, and SSN in the designated fields. Ensure accuracy as this information is crucial for processing.
3. Fill in the Patient Primary Phone Number and Referring MD Phone Number. This allows for effective communication regarding the referral.
4. Provide details about Primary Insurance Name, Benefits Phone Number, Plan ID Number, and Group Number. This information is essential for insurance verification.
5. Select the services required by checking the appropriate boxes. For imaging services like Pelvic Ultrasound, remember to note any preparation instructions provided.
6. Indicate the diagnosis by checking one or more options listed. If applicable, specify any other diagnosis in the space provided.
7. Finally, have the referring physician print their name, sign, and date at the bottom of the form before submission.

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