Get Bcbsm U.p. Blue Referral Form (pdf) - Bcbsm.com

Filling out the BCBSM U.P. Blue Referral Form is essential for initiating referrals to out-of-state or network providers. This guide will walk you through each section of the form to ensure a smooth submission process.

Follow the steps to complete the referral form accurately.

1. Click ‘Get Form’ button to obtain the BCBSM U.P. Blue Referral Form. Open the form in your preferred PDF editor.
2. Complete Section A: Patient Information. Fill out the patient's name, city of residence, date of birth, BCBSM group number, contract number, and the policyholder’s employer.
3. Move to Section B: Referring Michigan PPO Physician Information. Provide details about the referring physician, including their name, specialty, phone number, fax number, address, city, state, ZIP code, license number, BCBS pin number, and NPI number. Ensure the referring physician signs and dates this form.
4. Fill out Section C: Out-of-State/Network Physician/Laboratory/Facility Information by indicating the name, specialty, phone number, fax number, address, city, state, and ZIP code of the provider or facility where the patient is being referred.
5. In Section D: Reason for Referral, specify the services being requested, include diagnosis codes, anticipated start and end dates, frequency of visits, and the rationale for the out-of-state/network referral.
6. Lastly, review your entries thoroughly for accuracy. Once all sections are completed, fax the form and any necessary documentation to 906-225-9268.

Complete your BCBSM U.P. Blue Referral Form online today for timely processing.