Which information goes on a referral form?

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

Answer: (B)

When a referral is made, the form should provide enough information to identify the patient, direct the referral to the right provider, and explain why the patient is being referred. The most essential elements are the patient demographics (name, date of birth, contact information), the referring physician’s name and contact details, the diagnosis or reason for the referral, and the patient’s insurance information. This combination helps the receiving clinician locate the patient in the system, understand the clinical question, coordinate care, and verify coverage.

Dates of service alone don’t give the necessary identifying, clinical, or billing information. A treatment plan is something developed after the patient is seen and evaluated, not what’s needed to initiate a referral. A phone number by itself lacks the full set of required details to route and process the referral effectively.