Get Tricare East Referral Form Printable

This guide provides clear, step-by-step instructions for completing the Tricare East Referral Form Printable online. By following these instructions, users can ensure that they accurately provide all necessary information for a successful referral.

Follow the steps to complete the form with ease.

1. Click 'Get Form' button to access the referral form and open it in your selected editor.
2. Fill in Section I: Patient Information. Enter the patient's last name, first name, middle initial, date of birth, address, city, state, zip code, sponsor's Social Security Number, sponsor's name, and phone number.
3. Proceed to Section II: Other Health Insurance. Provide details on the policy holder, policy ID number, carrier name, effective date, carrier phone number, and indicate if service is approved by other health insurance.
4. In Section III: PCM Information, input the contact person for the primary care manager (PCM), their phone and fax numbers, PCM's name, signature, and the specialty to which the person is being referred, including contact details of the specialist.
5. Fill out Section IV: Referral Information. Check the appropriate boxes to indicate the type of referral, such as evaluation, treatment, home health, or surgical procedure. Specify inpatient or outpatient as necessary.
6. Section V: Codes requires you to enter the ICD-9 diagnosis code or description of the diagnosis, and any relevant CPT codes.
7. In Section VI: Clinical Information, include any additional documentation that supports medical necessity, such as clinical history and treatment plans. Indicate if additional information is submitted.
8. Finally, complete Section VII: Anticipated Discharge Needs by marking any anticipated needs such as durable medical equipment, home health, or rehabilitation needs.
9. Review all sections for accuracy. Once completed, save changes, download, print, or share the form as needed for submission.

Start filling out your Tricare East Referral Form Printable online now to streamline your referral process.