Sample Forms

Medical Service Request Form

October 10, 2014

The healthcare industry is obligated to provide the utmost care and sincere advice to its patients, regardless of their caste or color. It overlooks all the other differences and considers patients their priority. The healthcare department of every country runs on policies devised by its government, and every employee is strictly responsible for abiding by these rules without any excuses.

What is a medical service request form?

A medical services request form is a document that is required to seek medical services from healthcare providers. These request forms are a necessity while seeking medical help because they outline the structure of how things work at a hospital. These medical services may include:

  • Diagnostic test: these request forms are filled at laboratories while signing up for a diagnostic test, i.e. blood sample, pus sample, etc.
  • Medical procedure: during complicated surgeries, healthcare providers make sure that patients and their relatives are aware of the risky surgery and chances of survival; therefore, they seek special permission to respect patients’ wishes after the unfortunate event.
  • General observation: many times, patients seek a second opinion for diagnosing their disease; therefore, they acquire the help of healthcare professionals to review their diagnosis and tests from a fresh start.
  • Ailment treatment: Minor ailments are also treated after filling out the request form with a detailed description of the situation. E.g. small burns, bruises, cuts, etc.
  • Referral forms: referral forms are the documents that are devised by physicians for referring a patient to a specialist. These referral forms are also categorized as medical service request forms.
Medical Service Request Form
Sample
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These request forms are found everywhere in the healthcare industry to make sure that patients are aware of their rights regarding medical services. Mostly, caregivers at the healthcare facility fill out these forms on behalf of the patient by asking questions mentioned on the form. Relatives accompanying patients can also fill out these forms.

Request forms act as a communication bridge between doctors and patients because all the information about the physical health of a patient is described on the form.

Generic format of the form

Medical service request forms are usually simple and may include some questions to make a detailed case of the patient’s condition and what kind of assistance they require from healthcare providers. These forms are usually filled out by relatives of the patient to make sure that the correct information enters the system.

The type of information acquired in a medical service request form may include:

  • Patient’s information: name, age, address, weight, blood group, and date of birth are all required for filling out the patient’s biodata.
  • History: mentioning the history of the patient is crucial for healthcare providers because it includes all the previous surgeries, allergies, reactions to medications or food items, medication underuse, etc. It helps doctors and physicians devise a suitable medication and treatment plan for the patient.
  • Insurance: insurance provided by the state usually covers small treatments and procedures; therefore, insurance information is provided so that it can be carried for the hospital bill.
  • The procedure required: the type of treatment required by the patient for their condition is explained in detail to help doctors understand the situation.

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