Student Health Center Referral Form
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2Student Health Center Referral Form
1. PATIENT INFORMATION
Member ID
Please enter Member ID as shown on card
Patient’s Name
Patient’s date of birth
Patient’s Gender
(Given Name, Family Name)
(MM/DD/YYYY)
Male
Female
Name of Insured Member
Insured’s date of birth
Patient’s Relationship to Insured
(Given Name, Family Name)
(MM/DD/YYYY)
Self
Spouse
Child
Name of Plan Program Sponsor
Insured’s current mailing address
Member Email
Member Phone Number
2. DIAGNOSIS – describe illness, injury or symptoms requiring treatment at the Student Health Center
Date of Accident or Onset of Symptoms
Was this an Auto Accident?
YES
NO
(MM/DD/YYYY)
Date of Visit to Student Health Center
YES
NO
Was this a Sports Injury?
(MM/DD/YYYY)
Description/Details of Injury/Illness
(attach additional notes if necessary)
3. REFERRAL INFORMATION – describe what treatments/services/procedures the student is being referred for by the Student Health Center
Provider Type (i.e., specialists, laboratory
services, radiology, therapy, etc.)
Services Requested
Name of Authorized Referring Clinician
Clinician Signature, MD, NP, RN
Date
Facility Tax Identification Number (TIN)
GeoBlue Referral Form Rev. 07/16
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Parent category: Medical