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Doctor Referral Form Template

Create Quick and Efficient Doctor Referrals

Struggling to keep your patient referrals organized and efficient? This Doctor Referral Form Template helps healthcare providers streamline the referral process, ensuring timely communication between doctors. With customizable fields, you can gather essential patient information, track referrals easily, and maintain accurate records for better patient care. Plus, it enhances collaboration between specialists, reduces administrative delays, and ensures compliance with regulatory standards, all while being WCAG-aligned for accessibility. Start using this template to simplify your referral process today.

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Referring provider full name
Practice or facility name
Specialty
Practice phone
Practice fax
Provider email
NPI number
Patient full name
Date of birth
Patient phone
Preferred language
Primary insurance provider
Member ID / Policy number
Prior authorization number (if applicable)
Prior authorization status
Obtained
Not obtained
Not required
Unknown
Primary reason for referral
Provisional diagnosis or ICD-10 code(s)
Urgency of referral
Routine (3-6 weeks)
Soon (1-2 weeks)
Urgent (48-72 hours)
Not specified
Services requested
Consultation only
Evaluation and management
Diagnostic testing
Procedure
Ongoing management
Second opinion
Other
Please Specify:
Prior tests relevant to this referral
Current medications
Allergies
How will supporting records be sent?
Fax
Secure email
Patient will bring to appointment
Not sending / None available
Telehealth acceptable for this referral?
Yes
No
Patient availability for appointment
Mornings
Afternoons
Evenings
Weekdays
Weekends
No preference
Who should receive scheduling updates?
Patient
Referring provider
Both
Patient authorization to release relevant medical information has been obtained
Yes
No
Referring provider signature (type full name to sign)
Date signed
I attest that the information provided is accurate
Yes
No
{"name":"Referring provider full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Referring provider full name, Practice or facility name, Specialty","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a doctor referral form for an article on FormCreatorAI

When to use this form

Use this template when you need to hand off a patient to a specialist, hospital service, or imaging center. Examples include a PCP sending a patient with an abnormal EKG to cardiology, an urgent care escalating a hand fracture to orthopedics, or a telehealth visit moving abdominal pain to in-person evaluation. It standardizes identifiers, clinical reason, urgency, and attachments so the receiving team can triage fast and book the right slot. If the request is for in-home support, route it to the Home health referral form or the Home care referral form. When patients start the process themselves, pair this with the Self referral form to capture their goals and contact details.

Must Ask Doctor Referral Questions

  1. What are the referring provider's name, NPI, and contact details?

    This identifies who is accountable for the handoff and how to reach you for clarifications. Including NPI speeds record matching and payer-required documentation.

  2. What is the patient's full name, date of birth, medical record number, insurance ID, and best contact number?

    These identifiers prevent mismatched charts and help verify coverage before scheduling. A direct phone enables fast triage and appointment setup.

  3. What is the clinical reason for the referral, suspected diagnosis, and urgency level?

    Clear clinical context guides triage and ensures the patient is booked with the right service and timeframe. It also sets expectations for the consult scope.

  4. To which specialty or clinician are you referring the patient, and what is the preferred location?

    Naming the destination prevents misrouting and delays. Location preferences improve access for the patient and reduce rescheduling.

  5. Which recent notes, labs, and imaging are attached, with dates and facilities?

    Up-to-date documentation supports safe, efficient decisions and avoids duplicate tests. Dates and sources let the receiving team retrieve full reports if needed.

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