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Phone Room Form - General
"
*
" indicates required fields
Hidden
contactId
Online or Fax
Online
Fax
Locations
SC
SPC
SQC
MVC
RC
BHC
Date referral received
MM slash DD slash YYYY
Referred to
None
KLB
MRB
BGB
EAB
WC
BDC
MC
ERF
LMG
PBG
SPH
SLH
ASH
SQC Resident
PEI
LJJ
KJK
DSK
AAK
ASM
JAM
MP
SES
KCS
KJT
JLW
SY
JAY
What doctor was referred to?
Applicable when "Referred To" dropdown is "None"
Referred By
First
Last
Patient Name
First
Last
Phone
*
Patient DOB
MM slash DD slash YYYY
Date of call
MM slash DD slash YYYY
Result of call
Voicemail
No answer
Bad number
Will call back
Call back on
Call back on
MM slash DD slash YYYY
Scheduled
Yes
No
Date of Service
MM slash DD slash YYYY
Notes
Fax returned
Yes
No
Reason
Insurance Issue
Patient Declined
Patient scheduled elsewhere
Patient did not respond
Bad contact info
Referred out
Condition not treated
Note for condition & location referred
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