Get 900-4216-0114 Hopeblue Care Program Referal Form Ref Guide

Filling out the 900-4216-0114 HopeBlue Care Program Referral Form can streamline communication between Florida Blue Case Management and palliative care providers. This guide offers clear, step-by-step instructions on how to complete the form effectively online.

Follow the steps to fill out the referral form accurately.

1. Press the ‘Get Form’ button to access the form and open it for completion.
2. In the 'Referral to' section, enter the name of the provider and their NPI number. Ensure accuracy to facilitate the referral process.
3. Fill in the 'Date' field with the date on which the referral is being made.
4. Provide 'Provider Contact Information,' including the name and phone number of the provider's office contact.
5. Indicate the 'Location of Member' by checking the relevant option: Home, Hospital, Assisted Living Facility (ALF), Nursing Home (NH), or Request Clinic Appointment.
6. Enter the member's information, including their first and last name, identifier number, date of birth (DOB), and gender.
7. Complete the insurance details by inputting the member contract number and group number.
8. Specify the policy subscriber's name and their relationship to the patient.
9. Identify a member contact person and provide their phone number.
10. Fill out the member's address, including city, state, and zip code.
11. In the 'Primary/Attending MD Name' section, write the name of the primary physician and provide their contact information.
12. Detail the reason for the visit by checking all applicable options. This could include pain management, goals of care planning, and others.
13. Confirm whether the patient has consented to enter the program by checking ‘Yes’ or ‘No.’
14. Indicate if the attending provider has been notified of the referral and whether the primary care provider has been contacted.
15. If applicable, enter the primary care provider's authorization number for Medicare Advantage HMO.
16. Provide any modifications to the reasons for consultation if necessary.
17. Complete the appointment confirmation section with the date, time, and location of the scheduled appointment.
18. Once all sections are filled out, you may save changes, download the form, print it, or share it as needed.

Encourage others to complete the necessary documents online for efficient management and communication.