Mayo Clinic Referral Form – Fill Out and Use This PDF

At Mayo Clinic, getting a referral form is easy. A simple phone call to an affiliated provider will get you on your way. Once the referral form has been approved, patients can access cutting edge medical technologies and treatment modalities in diagnosis and management of complex conditions. The clinic's well trained staff provides superior care with dedicated patient advocacy. As one of the top choices for residents in the area seeking quality health care services, Mayo Clinic Referral Form ensures patients that their visit is handled quickly and correctly every time.

Mayo Clinic Referral Form PDF Details

Are you looking for a reliable healthcare provider? Have you ever felt confused, stressed, or stuck when trying to book an appointment with your doctor? If so, the Mayo Clinic Referral Form is here to help. This online form can help simplify the process of requesting medical referrals from leading healthcare providers, such as Mayo Clinic and its affiliates. Read on for more information about how this convenient online tool works and what it can do for you!

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

Form Preview Example

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

How to Edit Mayo Clinic Referral Form Online for Free

You'll be able to work with mayo clinic referral fax effectively with our online editor for PDFs. To retain our editor on the forefront of practicality, we work to put into practice user-oriented features and improvements regularly. We're always looking for feedback - play a pivotal part in revolutionizing how we work with PDF docs. This is what you'd need to do to begin:

Step 1: Just click on the "Get Form Button" above on this page to start up our pdf file editing tool. This way, you will find all that is necessary to fill out your document.

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

Step 3: Soon after proofreading your filled in blanks, hit "Done" and you are all set! Sign up with us today and immediately access mayo clinic referral fax, all set for download. Every last change you make is handily saved , helping you to change the document at a later time if necessary. FormsPal ensures your data privacy via a protected method that in no way records or shares any type of personal data typed in. Be confident knowing your files are kept safe when you work with our editor!

Mayo Clinic Referral Form – Fill Out and Use This PDF

Mayo Clinic Referral Form PDF Details

Form Preview Example

How to Edit Mayo Clinic Referral Form Online for Free

Mayo Clinic Referral Form isn’t the one you’re looking for?

Related Documents