week 6 hs210

Included with Referral Form:

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.

Blackburn Primary Care Associates, P.C

2500 Blackburn, Wisconsin Madison 12345

Phone: 608-222-9797

Fax: 608-222-9898

Patient Referral Form

Patient Name Phone #

SS# DOB

Diagnosis (ICD-10 Required)

Insurance Type

Referring Physician Phone#

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Consult Only Chiropractic

Evaluation and Treatment Physical Therapy

Inpatient Surgery Podiatry

Inpatient Admissions Back in Action Rehab Program

Outpatient Surgery Psychophysiological Evaluation

Outpatient Lab Biofeedback

Procedure Only Other

Referral Timeframe:

First Available Appt (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.

Referral for:

Copy of Insurance Card Demographic Information Treatment Notes Diagnostic Reports

Hospital/Facility

Mercy Hospital Presbyterian Hospital Outpatient Surgical Complex Health and Wellness Center

Comment:

Completed By: corey williams