Part 3, Chapter 14: Manual Appendix A

INSTRUCTIONS (This form may be used by Medical, Dental, and Paramedical personnel to refer DIH Beneficiaries for medical, dental or related services)

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1. TO Name, title, and address of person or organization or institution to whom referral is made)
   
   
   
   
2. NAME OF PATIENT (Last Name, First Name, Middle Name)
   
   
   
   
3. SEX______
   
   
   
   
4. BIRTH DATE_______
   
   
   
   
5. REGISTRATION NO. _______
   
   
   
   
6. ADDRESS
   
   
   
   
7. TRIBE
   
   
   
   
8. RESERVATION
   
   
   
   
9. REASON FOR REFERRAL (Type of service requested)
   
   
   
   
   
   
   
   
10. SIGNIFICANT MEDICAL OR DENTAL FACTORS (Including diagnosis, prognosis, treatment, etc.)
    
    
    
    
    
    
    
    
11. REPORT BY PARAMEDICAL PERSONNEL
    
    
    
    
    
    
    
    
12. FROM (Name, title, and address of person making referral)
    
    
13. DATE_______