Mayo Clinic Referral Form – Fill Out and Use This PDF

The Mayo Clinic Referral Form is a critical document used for referring patients specifically for colon and rectal surgery consultations at Mayo Clinic. It includes fields for detailed patient information, referring physician details, and specifics about the medical need, ensuring a seamless transition and coordination of care. If you're a healthcare provider seeking to refer a patient for specialized surgery at Mayo Clinic, filling out this form accurately is the first crucial step.

Click the button below to ensure your referral is processed efficiently and your patient receives the care they need.

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Mayo Clinic Referral Form PDF Details

When medical professionals or patients face complex medical needs, especially concerning colon and rectal surgery, accessing specialized care is crucial. Among the reputable institutions providing such specialized services, the Mayo Clinic stands out. Those seeking referral for Colon and Rectal Surgery at Mayo Clinic must navigate through a specific procedure underpinned by a detailed referral form. This essential document encompasses several sections, including detailed instructions for the referring physician, encompassing the physician’s contact information, patient information noting key demographics and insurance details, the urgency of the appointment, and the specific nature of the referral, including symptoms, diagnosis, and any prior treatments or surgeries relevant to the case at hand. The form also inquires about whether the patient is involved in workers’ compensation or litigation related to their condition, which could influence the approach to treatment or evaluation. Additionally, the referral form leaves space for preferred dates for scheduling the appointment, highlighting the Mayo Clinic's commitment to accommodating patient needs. The referral process culminates with a section dedicated to the Mayo Clinic's reply, ensuring clear communication regarding the appointment details. This systematic approach not only facilitates a streamlined referral process for colon and rectal surgery at one of America's top medical institutions but also exemplifies the Mayo Clinic's dedication to providing accessible, high-quality patient care.

Question	Answer
Form Name	Mayo Clinic Referral Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	mayo clinic referral forms, mayo clinic fax referral form, mayo clinic referral sheet pediatric orthop, mayo clinic referral form

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Colon and Rectal Surgery Referral to Mayo Clinic

Mayo Clinic Colon and Rectal Surgery Fax Referral Line • 507-284-1794

For other non-colorectal surgery referrals to Mayo Clinic, please call 1-800-533-1564 or go to www.mayoclinic.org/medicalprofs-rst/ and download a general referral form.

Referring Physician Information

REFERRING PHYSICIAN’S NAME

OFFICE ADDRESS

DATE (MO-DAY-YEAR)

UPIN #

CITY

STATE

ZIP

TELEPHONE

REPLY TO FAX #

NAME

Patient Information

FIRST	MIDDLE INITIAL	LAST	SEX	MAYO CLINIC #
Patient Name			MALE	FEMALE

ADDRESS				COUNTY

CITY

STATE

ZIP

DATE OF BIRTH (MO-DAY-YEAR)

HOME TELEPHONE

WORK TELEPHONE

PARENT’S NAME (if minor)

MAIDEN NAME

SPOUSE’S FIRST NAME

DOES THE PATIENT HAVE MEDICAL INSURANCE?		DOES THE PATIENT BELONG TO AN HMO?			IS THE PATIENT ON MEDICAL ASSISTANCE (MEDICAID)
YES	NO	YES	NO		YES	NO

IS WORKERS’ COMPENSATION OR LITIGATION INVOLVED?		IF YES, PATIENT IS REFERRED FOR —					DATE OF INJURY (MO-DAY-YEAR)
YES	NO	DISABILITY EVALUATION		TREATMENT/SURGERY

Appointment Request

REQUESTED APPOINTMENT				DATE(S) PREFERRED FOR SCHEDULING PARAMETER
EMERGENT	URGENT (< 3 Days)	4 – 14 DAYS	ROUTINE	TO

REASON FOR REFERRAL/SYMPTOMS/DIAGNOSIS (Please be specific and state area of involvement) —

ONSET/DURATION

DATE(S) OF PREVIOUS SURGERIES/PREVIOUS TESTING

SPECIFIC CONSULTANT REQUESTED

Mayo Clinic Reply

APPOINTMENT DATE (MO-DAY-YEAR)

DEPARTMENT / PHYSICIAN

REPORT LOCATION / TIME

NOTES

If the appointment scheduled is more than one week in the future, a letter of confirmation will be mailed to the patient.

Thank you for referring your patient to Mayo Clinic.

MC0688-23_WIP1VL

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Step 2: Once you launch the online editor, you will find the form made ready to be completed. Aside from filling out different fields, you may also perform other actions with the file, specifically putting on your own words, editing the original text, adding images, signing the PDF, and much more.

With regards to the blank fields of this specific form, this is what you need to do:

1. The mayo clinic referral fax will require specific information to be entered. Be sure the following blanks are filled out:

Writing part 1 of fax referral form mayo clinic

2. The third part is usually to fill out the following fields: YES, DISABILITY EVALUATION, TREATMENTSURGERY, Appointment Request REQUESTED, DATES PREFERRED FOR SCHEDULING, EMERGENT, URGENT Days, DAYS, ROUTINE, REASON FOR, ONSETDURATION, DATES OF PREVIOUS, SPECIFIC CONSULTANT REQUESTED, and Mayo Clinic Reply.

fax referral form mayo clinic writing process detailed (step 2)

It is possible to get it wrong when completing the DISABILITY EVALUATION, so make sure to take a second look before you'll send it in.

3. This third step is considered pretty straightforward, Mayo Clinic Reply, APPOINTMENT DATE MODAYYEAR, DEPARTMENT PHYSICIAN, REPORT LOCATION TIME, NOTES, If the appointment scheduled is, Thank you for referring your, and MCWIPvl - all of these empty fields must be filled out here.

MCWIPvl, REPORT LOCATION TIME, and Thank you for referring your in fax referral form mayo clinic

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Mayo Clinic Referral Form – Fill Out and Use This PDF

Mayo Clinic Referral Form PDF Details

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