Get Humana Referral Form

Filling out the Humana Referral Form online is an essential process for individuals seeking behavioral health referrals. This guide provides clear steps to complete the form efficiently, ensuring that all necessary information is accurately captured.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the beneficiary's full name in the 'Beneficiary Name' field. This ensures that the form correctly identifies the individual for whom the referral is being made.
3. Input the date of birth for the beneficiary to confirm their eligibility and relevance of the referral.
4. Select the appropriate insurance information by checking ‘Prime’, ‘Standard’, or ‘Other Health Insurance’ as applicable.
5. Fill in the beneficiary's street address, city, state, and zip code in the corresponding fields to provide current contact information.
6. Enter the sponsor's social security number accurately to identify the support individual relating to the beneficiary.
7. Complete the 'Patient ID' field to link the referral to existing patient records.
8. Provide the 'Phone Number' for the beneficiary or responsible person, ensuring a point of contact for follow-up.
9. Input the provider details including the office mailing address, city, state, and zip code.
10. List the primary care manager (PCM) and attending mental health provider details along with their contact information.
11. Detail the diagnosis, clinical history, and reasons for referral in the specified section. Include relevant social problems and any clinical information that could support the referral.
12. Designate a point of contact for more information, filling out their name and phone number.
13. Indicate whether the beneficiary is currently inpatient and if so, specify the facility name.
14. Record the date of referral and the name of the individual making the referral along with their title.
15. Fill out the phone and fax number for the person making the referral.
16. Complete the 'Fax Number for Case Management Acceptance Decision' to direct communications accurately.
17. Finally, save the changes, download, print, or share the form as needed.

Take the next step by completing the Humana Referral Form online today.