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Physician Referral Checklist

Making a referral? This checklist will help you (or a staff member) get organized.

Initial Contact Information

Your Practice Information:

Practice name
Your name
Address
Phone number
Fax number
Email address

Information About Your Patient:

Name
Name of parent or guardian (if the patient is a minor)
Birthdate
Address
Phone number
Social Security number
Insurance information

Has the patient previously been seen by a Highland Hospital or URMC physician? If so:

Name(s) of physician(s)
Date(s)

If your patient belongs to an HMO or managed care plan, you may need to submit an approved referral form before the patient’s first visit including the number of visits authorized.

For the Patient's First Visit:

Medical History and Records
Medical history
Clinical summary
Growth charts (for children)
Past surgeries/procedures
Devices: type/settings

Current Medications:

Type(s)
Dosages
Allergies

Basic Diagnostic Tests:

X-rays plus report
CT scan images plus report
Ultrasound images plus report
MRI images plus report
Pathology slides
Blood work report
Urine test report

Specialized Diagnostic Tests (if any have been done):

Echocardiogram: actual tape plus report
Thallium stress test: actual x-ray film plus report
Electrocardiogram: actual tracings if available
Electrophysiology test: actual tracings and reports
Cardiac catheterization: actual film plus report
Electroencephalogram (EEG) report
Nerve conduction study (NCS) report
Electromyography (EMG) report
Other

Please ask your patient to bring in all medications, including over-the-counter drugs, any self-monitoring records, and any self-monitoring devices, such as a blood glucose meter. Before the appointment, your patient may receive instructions for the visit.