Medical Referral Request Form Template
Streamline specialist referral requests with a form that captures all necessary clinical and administrative information for seamless specialist coordination.
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What is a Medical Referral Request Form?
A referral request form enables primary care providers to formally request specialist consultations for patients. It documents the clinical reason for referral, relevant medical history, and administrative details (insurance, urgency) needed for specialist scheduling.
Well-designed referral forms improve specialist access, reduce delays, and ensure specialists have sufficient clinical information to prepare appropriately. They serve as communication between primary and specialty care, improving care coordination.
Healthcare systems use referral forms to manage specialist demand, prioritize urgent cases, and track referral outcomes. Referrals may be required by insurance plans for specialist coverage.
Key Features
Patient Identification
Captures patient demographics and identifier information
Clinical Indication
Documents reason for referral and relevant clinical findings
Specialty Selection
Dropdown list of medical specialties (cardiology, orthopedics, etc.)
Urgency Prioritization
Allows routing of routine vs. urgent specialist consultations
Medical History Context
Captures relevant past medical history, medications, and allergies
Insurance Verification
Confirms coverage and obtains authorization if required
Why Use This Template?
Faster Access to Specialists
Complete referral information enables quicker specialist scheduling
Better Prepared Visits
Specialists receive clinical context before patient appointment
Insurance Authorization
Verify coverage and obtain authorization before specialist visit
Improved Care Coordination
Formal referral process tracks specialist consultations and outcomes
What's Included in This Template
Patient Name & Date of Birth
textPatient identification for referral routing
Referring Provider
textPrimary care provider initiating the referral
Specialty Requested
selectTarget medical specialty for consultation
Clinical Indication/Reason for Referral
textareaExplains why specialist consultation is needed
Urgency
selectDetermines priority (routine vs. urgent)
Relevant Medical History
textareaProvides clinical context for specialist preparation
Current Medications
textareaInforms specialist about medication interactions
Insurance Authorization Required
checkboxConfirms authorization requirement for specialist coverage
Perfect For
Primary Care Clinics
Requesting specialist consultations for patient complications
Hospital Internal Medicine
Hospitalist referral requests for specialty consultation
Urgent Care Centers
Referrals from urgent care to specialists for follow-up care
Healthcare Networks
Inter-facility referral requests within hospital systems
Frequently Asked Questions
Should all specialist consultations require a referral form?
Insurance requirements vary. HMOs typically require referrals for specialist coverage. PPOs may not. Check your insurance contracts and patient plans. Many systems use referrals for care coordination even without insurance requirements.
How long should it take to get an appointment after referral?
Routine referrals: 2-4 weeks depending on specialty availability. Urgent referrals: same week or days. Set clear expectations and escalate if specialist can't schedule within expected timeframe. Track referral-to-appointment time as quality metric.
Should I include test results with the referral?
Yes - attach or reference relevant test results, imaging, or clinical notes. Specialists need this context to prepare appropriately. But don't overwhelm with every test ever done - focus on recent, relevant findings.
How do I track specialist recommendations back to primary care?
Request that specialists submit consultation notes to the referring provider. Use your EHR to link referral requests to specialist reports. Some systems automate this; others require manual follow-up. Tracking referral outcomes improves care coordination.
What if a patient wants to choose their own specialist?
Most health plans require referral to in-network specialists. If patient wants out-of-network specialist, that may require special authorization or be covered differently. Discuss insurance coverage options and out-of-pocket costs upfront.
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