Attachment_E_-_FOH-74_Referral_Ticket_(M.89).pdf

FEDERAL OCCUPATIONAL HEALTH

Health Services Referral Ticket

NAME (Service Recipient): FOH Customer Agency:

Appointment Date (or instruction):

Requested Service: Requesting Physician:

INSTRUCTIONS TO EMPLOYEE:

− YOU MUST provide this sheet to vendor and instruct them to attach it to the invoice.

− DO NOT provide any personal information (other than your Social Security # and/or Date of Birth), which may be required as identifying information for your X-Ray.

− DO NOT provide your home or mailing address to the vendor. If you must give one, use the address of the health center (see below) that referred you.

− DO NOT use this form if issued beyond expiration date (see below).

NAME (Vendor): Phone:

Address:

INSTRUCTIONS TO SERVICE PROVIDER: --Tests and Procedures are for Screening Purposes only − DO NOT request any personal information from client (other than Social Security # and/or Date of Birth); if you have questions concerning exam, contact the FOH staff who scheduled the service (see below).

− DO NOT bill the patient. Send the invoice to the address shown below and, if billing questions, call the FOH health professional who scheduled the service.

− DO NOT accept this request past expiration date, which is: .

− DO be sure to attach this form to the invoice and also x-ray film (if applicable).

SEND invoice and test summary/report to: SEND original results/film to:

RMO B-Reader Kansas City Records Center

(if actual test results include x-rays) Other instructions attached Clinic Address Below: Address Below:

NAME (FOH Staff POC): Phone: Site Code:

INSTRUCTIONS TO FOH STAFF:

− DO indicate purchase order (provided by procurement staff) or other identifying number: .

− YOU MUST indicate Work Order number where service will be fulfilled − DO remind employee to provide this form to vendor and to provide only clinic address information. Retain a copy for the medical record.

Nurse Signature: _______________________________________ Date: ____________________

FOH-74 Service Referral Ticket Effective 6/2009