REFERRAL / SCHEDULE BY FAX FORM 2025

1. Click ‘Get Form’ to open the REFERRAL / SCHEDULE BY FAX FORM in the editor.
2. Begin by entering the patient's name and contact information in the designated fields. Ensure accuracy for effective communication.
3. Fill in the patient’s insurance details, including policy and group numbers, along with their date of birth. This information is crucial for billing purposes.
4. Provide details regarding workers' compensation if applicable, including attorney information and authorization number.
5. In the diagnosis section, write down the required ICD-10 code clearly to avoid any processing delays.
6. Ensure that the physician's signature is included along with their printed name for validation.
7. Select the appropriate imaging tests by checking the relevant boxes. Be thorough to ensure all necessary procedures are scheduled.
8. Finally, review all entered information for accuracy before saving or sending your completed form through our platform.

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