Fillable Referral Request Thank you for choosing Marsheld Clinic

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Referral Request Thank you for choosing Marsheld Clinic

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The Referral Request Thank you for choosing Marsheld Clinic form is 1 page long and contains:

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Date Referring provider name
Referring provider phone number Fax number
Practice name of referring provider
Practice address of referring provider
Patient name Date of birth
Has patient received medical care under another name:
l Yes l No If yes, name ______________________________________________________
Patient’s contact number Alternate
Patient’s home address
Patient’s primary care provider
Referred to specialty Location requested
Specic provider (if desired)
Urgency: l Days l Weeks l Schedule permitting l Elective
Emergent referrals require provider-to-provider contact with the on-call specialist. Call us at 715-858-9191 to assist with this.
Diagnosis/Complaint (clinical question to be answered) ____________________________________________________________________________
If this referral is to the Pain Clinic, it is necessary to indicate if the patient is to be seen for:
l Medication management l Spine assessment l Potential injection
If this referral is to Behavioral Health, it is necessary to indicate if the patient is to be seen for:
l Medication management l Counseling l Neuropsychological testing The patient is a: l Child l Adult
Is this a work-related injury or illness: l Yes l No If yes, date of injury ____________________________________________________
Name of employer ___________________________________________________________________________ Liability accident: l Yes l No
Other relevant labs/imaging (date, study, location) __________________________________________________________________________________
Additional information (i.e. Does the patient have special needs, interpreter, hearing/visual impairment, etc.) ____________________
___________________________________________________________________________________________________________________________________________
Thank you for putting your trust in Marsheld Clinic Health System.
This Referral Request form is for internal processing only and is not part of the medical record.
9-32504-02 (07/20) © 2013 Marshfield Clinic Health System
External
Referral Request
Thank you for choosing Marsheld Clinic Health System. Please fax or email this form as well as any patient
demographics, insurance information, applicable clinical notes, pertinent pathology, labs, or imaging.
Fax number: 715-634-6543 Email address: rf.westreferral@marsheldclinic.org Questions – call: 1-877-857-3337
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Referral Request Thank you for choosing Marsheld Clinic

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Completed 22 January 2022

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