Patient Referral Form - Oral & Maxillofacial Surgery
This file is a Patient Referral Form for the Oral & Maxillofacial Surgery Department at Michigan Medicine. It provides essential information needed to refer a patient for specialized care. Completing this form ensures efficient patient triage and care provision.
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How do I fill this out?
To fill out this form, first gather all necessary patient information including demographics and insurance details. Complete the referring physician's section with accurate contact information. Finally, review the entire form for completeness before submission.
How to fill out the Patient Referral Form - Oral & Maxillofacial Surgery?
1
Gather patient information such as name, address, and insurance details.
2
Fill in the referring physician's name and contact information.
3
Specify the reason for referral clearly.
4
Review the form to ensure all sections are completed.
5
Fax the completed form to the designated fax number.
Who needs the Patient Referral Form - Oral & Maxillofacial Surgery?
1
Primary care physicians need this form to refer patients for specialized oral and maxillofacial care.
2
Dentists use this referral form to send patients for surgery or advanced treatment.
3
Orthodontists may require this form to refer patients needing additional surgical evaluation.
4
Insurance providers need this form to process claims related to oral surgery.
5
Patients seeking treatment require this form to initiate the referral process.
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What are the instructions for submitting this form?
To submit the Patient Referral Form, complete all relevant fields and ensure the accuracy of the information. Once filled out, fax the form to 734-615-6159 or send it to the Oral & Maxillofacial Surgery Department at 1500 E. Medical Center Dr., Med Inn Floor 2 Room C213, Ann Arbor, MI 48109. For any inquiries, please contact us at 734-936-4761.
What are the important dates for this form in 2024 and 2025?
There are no specific important dates for this referral form in 2024 and 2025. However, it is essential to submit it promptly to ensure timely care for referred patients.
What is the purpose of this form?
The purpose of the Patient Referral Form is to facilitate the smooth transition of patients from primary care or other dental specialties to the Oral & Maxillofacial Surgery Department. It collects essential information needed to assess, triage, and provide the necessary surgical care efficiently. By following this structured referral process, healthcare providers can enhance patient care and ensure effective communication between various specialties.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Contains details like name, address, contact number, gender, and insurance.
- 2. Referring Physician Info: Includes the referring physician's name, specialty, and contact details.
- 3. Reason for Referral: Specifies the medical or dental reasons for the referral.
- 4. Insurance Details: Documents relevant information regarding patient insurance coverage.
- 5. Additional Notes: Allows for any extra comments or instructions from the referring physician.
What happens if I fail to submit this form?
If this form is not submitted, the patient may face delays in receiving necessary surgical evaluation and treatment. Additionally, proper care coordination might be compromised, leading to complications in patient management.
- Delay in Treatment: Not submitting the form can result in postponed procedures and consultations.
- Miscommunication: Failure to provide necessary information may lead to misunderstandings between care providers.
- Increased Patient Anxiety: Patients may experience heightened concern regarding their care if referrals are not processed.
How do I know when to use this form?
- 1. Surgical Interventions: Use this form for patients needing surgical procedures such as extractions or jaw surgery.
- 2. Specialized Consultations: Appropriate for cases requiring expert evaluations that go beyond routine dental care.
- 3. Patient Follow-ups: Applicable for ongoing patient management needing referral to a specialist.
Frequently Asked Question
Can I edit the Patient Referral Form?
Yes, you can easily edit the form using PrintFriendly's PDF editor.
How do I submit the completed form?
You can fax the completed form to the provided number or share it directly through our platform.
Is it possible to add my signature to the PDF?
Absolutely, PrintFriendly offers a convenient tool to digitally sign your documents.
What types of information are required for this form?
You need to provide patient demographics, insurance details, and the reason for the referral.
How will this form benefit my practice?
Submitting this form ensures efficient patient care and helps you manage referrals seamlessly.
Can I download the edited PDF?
Yes, after editing, you can download the finalized document.
What do I do if the information changes?
Simply go back and edit the PDF to reflect any updated information.
Who should I contact if I have questions about using this form?
You can contact the Oral & Maxillofacial Surgery Department for any inquiries regarding the referral process.
Is there a way to track my referral submission?
You are advised to keep a copy of the fax or share confirmation for your records.
What happens if I don't submit this form?
Failure to submit the form may delay patient care and resource allocation.
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