D.C. Mun. Regs. tit. 26-A, § 4398 – Appendix 43-1: Uniform Consultation Referral Form

1 Patient Information		2 Carrier Information
Date of Referral:		Name: Address: Phone: Fax: Referral Number:
Name (Last, First, MI)
Date of Birth: (MM/DD/YY)	Phone:
Member#:
Site #:
3 Primary or Requesting Provider
Name: (Last, First, MI)			Specialty:
Institution / Group Name:		Provider ID:	Provider ID #: 2 (If Required)
Address: (Street #, City, State, Zip)
Phone Number:		Facsimile / Data Number:
4 Consultant / Facility Provider
Name: (Last, First, MI)			Specialty:
Institution / Group Name:		Provider ID:	Provider ID #: 2 (If Required)
Address: (Street #, City, State, Zip)
Phone Number:		Facsimile / Data Number:
5 Referral Information
Reason for Referral:
Brief History, Diagnosis and Test Results:
6 Service Desired	Provide Care as indicated:	7 Place of Service
☐ Initial Consultation Only ☐ Diagnostic Test: (specify) ☐ Consultation With Specific Procedures: (specify) ☐ Early, Periodic Screening, Diagnosis & Treatment ☐ Standing Referral ☐ Specific Treatment: ☐ Global OB Care & Delivery ☐ Other: (explain)		☐ Office ☐ Outpatient Medical/Surgical Center ☐ Radiology ☐ Laboratory ☐ Inpatient Hospital ☐ Extended Care Facility* ☐ Other: (explain) (Specific Facility Must be Named)
Number of visits: (If blank, 1 visit is assumed)	Authorization #: (If Required)	Referral is Valid Until: (Date) (See Carrier Instructions)
Signature: (Individual Completing This Form)		Authorizing Signature: (If Required)