Edit, Download, and Sign the Patient Referral Intake Form - UCDAVIS Health System
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How do I fill this out?
To fill out this referral intake form, gather all necessary patient and provider information. Ensure each section is completed to avoid delays. Review your entries for accuracy before submission.
How to fill out the Patient Referral Intake Form - UCDAVIS Health System?
1
Obtain the necessary patient and referral provider details.
2
Fill out each section of the form accurately.
3
Indicate if an interpreter is needed and provide insurance details.
4
Attach any required supporting documents.
5
Submit the completed form via fax.
Who needs the Patient Referral Intake Form - UCDAVIS Health System?
1
Primary Care Physicians (PCP) who need to refer patients.
2
Specialists requiring detailed patient information for consultations.
3
Insurance companies needing referral documentation.
4
Office administrators coordinating patient care.
5
Parents or guardians of minors for healthcare referrals.
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Upload your Patient Referral Intake Form to PrintFriendly.
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What are the instructions for submitting this form?
Completed forms should be faxed to 916-703-6048. Ensure the form is filled out completely and accurately to avoid delays. For assistance, contact the office directly via the provided phone numbers or email for clarification on the submission process.
What are the important dates for this form in 2024 and 2025?
Please check with UC Davis Health System directly for any important dates regarding referrals in the years 2024 and 2025.
What is the purpose of this form?
The purpose of the Patient Referral Intake Form is to facilitate the referral process for patients seeking specialized medical care. By collecting comprehensive information from both patients and referring providers, the form ensures seamless communication between healthcare professionals. This process is crucial for timely and effective patient treatment.
Tell me about this form and its components and fields line-by-line.
- 1. Patient's PCP: Indicates if the referrer is the patient's Primary Care Provider.
- 2. Referring Provider's Information: Collects details about the referring provider including name, address, and contact information.
- 3. Patient Information: Captures essential patient details including name, date of birth, contact information, and insurance.
- 4. Consultation Request Information: Contains information about the requested specialty, reason for referral, and additional details.
- 5. Insurance Information: Requests insurance details including primary and secondary coverage.
What happens if I fail to submit this form?
Failure to submit this form may delay the referral process and access to specialized healthcare. It is essential to ensure that all required fields are filled out accurately and completely. Missing information could lead to the necessity of resubmitting the form, further prolonging patient care.
- Delayed Patient Care: Incomplete or missing submissions can lead to extended waiting periods for patients.
- Insurance Issues: Errors may result in denial of insurance coverage if the submission is not accompanied by necessary documentation.
- Increased Workload: Resubmitting forms due to errors can increase the workload for office staff.
How do I know when to use this form?
- 1. Referring Patient to a Specialist: Used by PCPs to refer patients for specialized care.
- 2. Consultation Requests: Necessary for formal requests for second opinions or specialized evaluations.
- 3. Insurance Submission: Required documentation for insurance approval of referrals.
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Gather patient personal information, referring provider details, and insurance information.
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