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How do I fill this out?
To fill out the Cincinnati Fetal Center Referral Form, start by gathering all necessary patient information. Make sure to complete each section accurately to facilitate proper processing. Once the form is filled out, review it for completeness before submission.
How to fill out the Cincinnati Fetal Center Patient Referral Form?
1
Gather all necessary patient information.
2
Complete each section of the form accurately.
3
Review the form for completeness.
4
Attach required documents such as insurance cards and lab reports.
5
Submit the form via email or fax as per instructions.
Who needs the Cincinnati Fetal Center Patient Referral Form?
1
Obstetricians who want to refer patients for specialized care.
2
Pediatricians needing to transfer patients for fetal evaluations.
3
Family physicians looking for assistance with complex pregnancies.
4
Insurance providers requiring detailed referral information.
5
Hospitals needing to coordinate care for referred patients.
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What are the instructions for submitting this form?
To submit the Cincinnati Fetal Center Patient Referral Form, please send the completed form along with the required documents to cfcreferral@cchmc.org or fax it to 513-636-5959. Ensure you attach copies of the patient's insurance cards, progress notes, imaging reports, and relevant lab results. Timely submission is crucial for ensuring prompt processing and care.
What are the important dates for this form in 2024 and 2025?
The Cincinnati Fetal Center Referral Form should be submitted as soon as a referral is made, especially in emergent cases. Ensure all necessary documentation is provided promptly. This practice will guarantee timely patient care through our center.
What is the purpose of this form?
The purpose of the Cincinnati Fetal Center Patient Referral Form is to streamline the referral process for patients requiring specialized fetal care. By gathering essential patient information, the form facilitates faster pre-authorization for insurance coverage, improving the overall efficiency of care. Proper completion and submission of this form ensure that patients receive timely evaluations and treatments.
Tell me about this form and its components and fields line-by-line.
- 1. Referring Doctor: Name of the physician making the referral.
- 2. Phone number: Contact number for the referring physician's office.
- 3. Office address: Complete address of the referring physician's practice.
- 4. Fax number: Fax number for communication.
- 5. City, State, Zip: Location of the referring physician's office.
- 6. NPI: National Provider Identifier for the referring physician.
- 7. Patient Name: Full name of the patient being referred.
- 8. Home address: Patient's home address.
- 9. Best contact phone number: Preferred method of contact for the patient.
- 10. Suspected diagnosis: Diagnosis suspected by the referring physician.
- 11. Estimated gestational age: Estimated age of the fetus in weeks.
- 12. Estimated due date: Expected delivery date for the pregnancy.
- 13. Reason for referral: Justification for why the patient must be seen at the center.
What happens if I fail to submit this form?
If this form is not submitted, patients may face delays in receiving essential fetal care. Missing this step can lead to complications in pre-authorization for insurance, resulting in increased financial responsibility for patients. It is critical to ensure timely submission to avoid these concerns.
- Delay in Care: Patients may not receive timely assessments and interventions.
- Financial Implications: Patients could incur unexpected costs without pre-authorization.
- Coordination Issues: Referrals may not be processed promptly, impacting patient outcomes.
How do I know when to use this form?
- 1. High-risk Pregnancy: Used for patients deemed as high-risk who require specialized monitoring.
- 2. Abnormal Findings: Essential when abnormal results are noted during routine check-ups.
- 3. Transfer of Care: Utilized when a patient is being transferred from one care facility to the Cincinnati Fetal Center.
- 4. Insurance Pre-authorization: Necessary for obtaining medical insurance approval for referred patients.
- 5. Urgent Referrals: Required for patients needing immediate attention and evaluations.
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How important is completing the referral form accurately?
Accurate completion is crucial as it ensures smooth processing and prompt care for your patient.
Is there a specific order to fill out the form?
It is best to follow the sections in the order provided to ensure all information is captured.
What kind of documents should I attach?
Attach insurance cards, OB charts, and any relevant imaging and lab reports.
Do I need to send the form immediately?
Yes, sending the form promptly can accelerate the pre-authorization process.
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