Get Ohio Health Referral Form

Filling out the Ohio Health Referral Form online is a straightforward process that ensures your patient's information is accurately conveyed to the health care providers. This guide will walk you through each step needed to complete the form efficiently.

Follow the steps to fill out the Ohio health referral form online.

1. Click ‘Get Form’ button to obtain the Ohio Health Referral Form and open it in your browser.
2. Begin with the 'Patient Information' section. Enter the patient's name, date, address, city, state, and zip code. Make sure all provided information is accurate and up-to-date.
3. Next, fill in the main and alternate phone numbers, social security number, birth date, preferred language, and whether an interpreter is needed. If the patient has any special needs, specify them in the designated field.
4. Move on to the 'Referring Physician Information' section. Enter the printed name of the physician, their signature, office phone number, and fax number. Indicate who completed the form.
5. In the 'Reason for Referral' section, clearly state the reason for the referral and include the diagnosis code. If applicable, provide the Bureau of Workers' Compensation (BWC) diagnosis code and patient weight.
6. Fill out the insurance information, including attaching a copy of the insurance card and any relevant patient records. Provide the referral or authorization claim number and details about the insurance company.
7. Indicate the patient's needs for an appointment by checking the appropriate option: ASAP, within one week, or at the patient's convenience. Specify whether the office or patient should initiate the call.
8. Complete the 'Appointment Information' section, noting the scheduled date, time, physician, and location. Indicate if a new patient packet should be mailed.
9. Ensure to fax all associated office notes and prior testing with the referral form and remind the patient to carry any relevant films and reports unless already sent to OhioHealth.
10. Once all sections are filled out, review the document for accuracy. You may then choose to save changes, download, print, or share the completed form as needed.

Start completing your Ohio Health Referral Form online today for efficient patient referrals.