Affix SIU P&S
Label Here
DEMOGRAPHICS (to be completed by referral
coordinator)
Date:
____/____/____
Patient
Name: ___________________________________ DOB
____/____/____
SIU
Medical Record Number (if applicable): _________________________
Requesting
Physician or Non Physician Practitioner (NPP) :
__________________________
Phone:
(______)___________________ Fax: (______)______________________________
Address: _____________________________________________________________________
(to be completed by
physician, NPP, resident, or nursing staff)
q
CONSULTATION
q
Request for Consultation ONLY
q
Consultation and Begin Treatment/Management
if Indicated
State Patient’s Problem/Condition for which you seek an opinion: _______________________________________________________________________________________________________________________________________________________________________________________________________________
q
TRANSFER OF CARE
State Patient’s Problem/Condition: _______________________________________________________________________________________________________________________________________________________________________________________________________________
YOU MUST
RETAIN A COPY OF THIS FORM IN YOUR
PATIENT’S MEDICAL RECORD
(Alternatively,
if your office note contains a specific request for a consultation
or a transfer of care that is sufficient to meet the
CMS documentation guidelines)
_________________________________________ ___________________________
Signature of Requesting Physician
(or appropriate office staff) Date
Thank you for your cooperation and quick response. This procedure ensures compliance with certain billing and documentation requirements for consultations issued by the Center for Medicare and Medicaid. (CMS)