Otolaryngology Coding Alert

Consult or referral? Here's how to tell 100 percent of the time

Pinpoint whether a primary-care physician is asking for an opinion or referring a patient using this foolproof tool.

CONFIRMATION OF PATIENT APPOINTMENT

The following patient has made an appointment with our practice.
Patient Information:
Name: _______________________________ Medical Record Number: ____________________     DOB: ________
Telephone: (______) ____________________ Insurance:_________________________________________________

Please confirm the nature of the appointment.
Date of Request: _____________________ Appointment Date: ___________________
Requested by: _______________________ Address: ___________________________
Phone Number: ______________________ Fax: _______________________________

This appointment is being requested for my patient for the following reason:
Consultation for a specific problem   Referral for a specific problem 
Reason for consultation (please be specific):___________________________________________________________

________________________________________________________________________________________________

Signature of Requesting Physician: _________________________________________

Note: Please fax this completed form to our office at _____________________as quickly as possible. Failure to return the completed form may result in delay in scheduling the patient's appointment.
Please file completed form in the patient's chart.