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Otolaryngology Coding Alert

Stop Trying to Read the Requesting Physician's Mind -- Use This Confirmation Sheet Instead

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.


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Otolaryngology Coding Alert

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