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PART II: PATIENT REFERRAL FORM
HS-210 Medical Office Management
Week 6 Assignments
For this assignment, you will be completing an outpatient referral form for Jessica Smith (SS#
999-88-7777). Jessica is being referred by Dr. Hector Jones for a stat outpatient endoscopy
procedure at Mercy Hospital with Dr. Robert Hughes. Jessica’s diagnosis is acute peptic ulcer for
an unspecified site (ICD9-533.0). Jessica is insured with BlueCross/BlueShield and her date of
birth is 01/01/1970. Dr. Jones has requested that Jessica’s treatment notes be included with the
referral form along with a copy of her insurance card. Dr. Jones has also requested that Jessica be
contacted at 608-555-1212 when the referral form is ready for pick up.
BlackburnPrimaryCareAssociates,P.C
2500 Blackburn, Wisconsin Madison 12345
Phone: 608-222-9797
Fax: 608-222-9898
Patient Referral Form
Phone #
DOB
Patient Name
SS#
Diag
nosis (ICD-10 Required)
Insurance Type
Referring Physician
Phone #
3
PART II: PATIENT REFERRAL FORM
☐Consult Only
☐Evaluat ion and Treatment
☐Inpatient Surgery
☐Inpatient Admissio ns
☐Outpatient Surgery
☐Outpatient Lab
☐Procedure Only
Referral Timeframe:
☐First Available Apt (w/in 5 Business days)
☐Stat (w/in 24 hrs)
Provider:
☐Ron Lupez, M.D.
☐Donald Lawler, M.D.
☐Robert Hughes, D.O
☐Neil Stern, D.P.M.
☐Joel Lively, P.T.
☐Copy of Insurance Card
☐Demographic Info
☐Treatment Notes
☐Diagnostic Reports
HS-210 Medical Office Management
Week 6 Assignments
☐Chiropractic
☐Physical Therapy
☐Podiatry
☐Back in Action Rehab P
r
ogram
☐Psychophysiological Evaluation
☐Biofeedback
☐Other
3
PART II: PATIENT REFERRAL FORM
HS-210 Medical Office Management
Week 6 Assignments
Hospital/Facility
☐Mercy Hospital
☐Presbyterian Hospital
☐Outpatient Surgical Complex
☐Health and Wellness Center
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Completed 2 October 2021

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