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The Maryland Referral Form serves as a crucial tool in the healthcare system, facilitating communication between primary care providers and specialists. This form captures essential information, including patient details such as name, date of birth, and contact information, ensuring that the right care reaches the right individual. It outlines the roles of both the primary or requesting provider and the consultant or facility provider, detailing their specialties and institutional affiliations. The form also includes sections for the reason for the referral, brief medical history, and desired services, which helps streamline the process for both providers and patients. Additionally, it specifies the place of service, whether it be an office, outpatient center, or hospital, along with the number of visits anticipated. Importantly, the form emphasizes that while referrals are made, they do not guarantee payment, as reimbursement is contingent upon the patient's eligibility and the terms of their insurance plan. Understanding the components of this form is vital for ensuring that referrals are processed smoothly and effectively, ultimately leading to better patient outcomes.
Maryland Referral Preview
Form Attributes
| Fact Name | Description |
|---|---|
| Form Title | The form is officially called the Maryland Uniform Consultation Referral Form. |
| Date of Referral | Providers must include the date of referral at the top of the form. |
| Patient Information | Patient details such as name, date of birth, and phone number are required. |
| Governing Law | This form is governed by Maryland Health General Article ยง 19-303. |
| Consultant Information | Consultant or facility provider details must be clearly provided, including specialty. |
| Reason for Referral | A specific reason for the referral must be stated, along with relevant history and diagnosis. |
| Authorization Details | Authorization numbers and the validity period of the referral must be included. |
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