Patient Referral

Templates

Patient Referral

All

Healthcare

Use this template

Datapoint

Description

This is some text inside of a div block.

Referring Provider Name

Full name of the doctor or healthcare provider making the referral.

Referring Provider Contact Information

Phone number, email address, or clinic address of the referring provider.

Referral Date

The date the referral was issued.

Patient Name

Full name of the patient being referred.

Patient Date of Birth

Date of birth of the patient.

Patient Insurance Information

Insurance provider name, member ID, or group number (if included).

Receiving Provider or Specialist Name

Full name of the doctor, specialist, or clinic the patient is being referred to.

Receiving Provider Specialty

Specialty or field of the receiving provider (e.g., cardiology, dermatology).

Reason for Referral

Brief description of the medical concern or condition prompting the referral.

Requested Services or Evaluation Type

General category of treatment or evaluation being requested (e.g., imaging, surgical consult, specialist evaluation).

Urgency Level

Level of urgency (e.g., routine, urgent, STAT).

Supporting Documents Included

Yes/No indicator for included items like lab results, imaging reports, or prior visit notes.

Patient referrals document the transfer of care or consultation requests between healthcare providers, capturing essential details for coordination and continuity of care. Feathery’s AI extraction engine captures the referring provider’s name and contact information, referral date, patient name, date of birth, and insurance details. It also retrieves the receiving provider’s name, specialty, reason for referral, requested services, and urgency level.

The engine flags whether supporting documents such as lab results, imaging, or prior visit notes are included. This template is ideal for hospitals, clinics, and specialty practices seeking to automate referral intake, reduce administrative delays, and ensure all necessary information is accurately transferred to the receiving provider.

Related templates

ACORD 25

ACORD 26

ACORD 27

Medical Bill

Face Sheet