What information goes on a referral form?

• A. Date of service
• B. Treatment plan
• C. Phone number only
• D. Pt Demographics, Referring doctor, diagnosis/reason, Insurance Info

Answer: (D)

When a referral is asked for, the most important thing is to have identifying and administrative details that let the receiving clinic know who the patient is, where to reach them, who is sending the referral, why the referral is needed, and how it will be paid. The essential information includes the patient’s demographics (name, date of birth, contact information, address), the referring doctor’s name and contact details, the diagnosis or reason for the referral (what the specialist needs to evaluate or treat), and the patient’s insurance information. This combo ensures the patient is correctly identified, the referral goes to the right specialist, the purpose of the referral is clear for the evaluating clinician, and billing and eligibility can be processed.

Date of service isn’t determined yet and is something scheduled after the referral is accepted. A treatment plan is typically developed after the patient is evaluated by the specialist, not on the referral form. A phone number alone doesn’t provide enough information to route and process the referral properly.