Physician Referral Form

What is the purpose of the Physician Referral Form PDF?

The purpose of the Physician Referral Form PDF is to initiate the referral of an adult patient with a dual diagnosis of developmental disability and a mental health or behavioral concern to a specialist service in Calgary, Alberta. This intake document establishes that all five referral criteria are met and captures the presenting problem, medical history, medications, and contact information needed to start the intake process. Completing this form ensures patient details and clinical evidence are comprehensively documented for a structured submission.

Who uses the Physician Referral Form PDF?

You use this form as the patient's family doctor to refer them to a specialist service for developmental disabilities and mental health. If a specialist is initiating the referral, you still need to provide a supporting letter as the family doctor. The receiving center's intake team then uses the completed form to notify you and the caregiver when the referral is accepted, dispatch an intake package, and arrange an appointment once the package is returned.

What is included in a Physician Referral Form PDF?

A Physician Referral Form PDF captures the patient's personal details, referral criteria, clinical information, and the referring physician's details.

• Date
• Patient demographics: name, sex, date of birth, address, phone, and Personal Health Number
• Contact person details: name, relationship to patient, phone, and address
• Guardian details: phone and address
• Five required referral criteria, including evidence of IQ below 70 before age 18, age over 16, a behavioral or mental health concern, a complete physical in the past year, and a family doctor referral
• Presenting problem
• Past medical history
• Current medications
• Date last seen
• Referring physician’s name, PRACID number, address, phone, and fax
• Psychiatric services status, including current psychiatrist’s name if applicable

Common Problems of Completing Physician Referral Form PDFs

IQ Evidence Is Often Missing From the Chart

The referral requires documented evidence that the patient’s Full Scale IQ was below 70 before age 18. This evidence is often in a school psychology report or a pediatric assessment that is not in your current chart. Since a verbal report from the family is insufficient, chasing down the original source documentation with a clear date is a common cause of delay. Missing this one piece of evidence is a frequent reason referrals are rejected at intake.

The Recent Physical Creates a Sequence Problem

The requirement for a complete physical within the past year can create a workflow challenge, especially for older patients. The referral itself is often the reason the physical is scheduled, but the physical must be complete before the referral can be submitted. This sequencing problem means you have to coordinate the physical appointment, receive the results, and then finalize the referral package, which adds an extra step that can delay submission.

Specialist Referrals Have an Extra Coordination Step

When a specialist initiates a referral, the form still requires a supporting letter from the patient's family doctor. This adds a coordination step between the specialist's office and your practice that can frequently stall the process. The specialist has the initial clinical impetus, but you hold the key to the final submission, creating a communication and administrative hurdle that needs to be cleared before the intake team can even review the case.

Benefits of Using Heidi to Auto-Fill Physician Referral Form PDFs

The IQ Evidence Pulled Forward From Past Reports

You know the required IQ documentation is likely buried in an old school file or a past pediatric assessment in the patient’s chart. Heidi pulls that evidence forward, flagging the source and date so the referral meets the documentary standard the intake team requires. As a starting point for your review, this saves you the time spent hunting for old reports just to get the referral past the first gate.

A Triage-Ready Summary of the Presenting Problem

During the visit, you discuss the patient's behavioral patterns, triggers, severity, and prior interventions. Heidi transcribes the relevant parts of your conversation and assembles a summary of the presenting problem with the specificity the receiving center needs for triage. This avoids the back-and-forth that happens when a generic summary is sent, and ensures your clinical reasoning is clearly represented from the start.

Your Supporting Letter Drafted From the Record

When a specialist refers a patient, your supporting letter is the last piece needed. Instead of you writing it from scratch, Heidi drafts the letter from the patient's history in your practice record, including the clinical context that supports the referral. You review and edit the draft to finalize it, transforming the task from a writing assignment into a quick review and sign-off.