Get New Hampshire Referral Form - Anthem

Filling out the New Hampshire Referral Form - Anthem online can streamline the referral process and ensure that all necessary information is clearly presented. This guide provides detailed, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete your referral form online easily.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Enter the date at the top of the form to indicate when the referral is being completed.
3. Specify the name of the patient’s insurance carrier by selecting from the options provided.
4. Provide the patient’s date of birth in the required format (MM/DD/YY).
5. Indicate the reason for the referral in the respective section, making sure to include any necessary diagnosis information or ICD-9 code.
6. Fill in the 'Start Date' and 'Expiration Date' of the referral authorization.
7. In the 'Referring Physician' section, provide the full name and contact information.
8. For 'Office Visits' and 'Rehabilitation,' check appropriate boxes indicating the nature of the visit and specify the number of required visits.
9. Use the comments section to include any additional information or special requests relevant to the referral.
10. Finally, review all entered information for accuracy, save your changes, and download or print the completed form as needed.

Complete your New Hampshire Referral Form - Anthem online today.