Physician Referral Form - Vermont

Yes No

Is this service obtainable in Vermont?

Have efforts been made to find a closer provider?

Does the requested physician possess special expertise?

Is it medically necessary for this physician to treat this patient?

Does the patient have a history with this specific provider?

Please describe the specific service or medical care that this member needs a ride to:

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Is there a medical reason for someone to accompany the member on this trip?____________________

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Print name of Doctor or Doctor’s Staff providing information Phone

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Signature of Doctor or Doctor’s Staff providing information Date