Get Gateway Referral Form

Filling out the Gateway Referral Form online is a straightforward process designed to streamline referrals for Valley Health Plan. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. Click 'Get Form' button to access the Gateway Referral Form and open it in an online editor.
2. Enter the date in the designated field to indicate when the referral is being made.
3. Fill in the name of the Gateway staff person responsible for the referral in the provided space.
4. Complete the caller's name by entering their first name, middle initial (if applicable), and last name.
5. Enter the caller's date of birth in the specified format for identification purposes.
6. Indicate who the referral is made to by writing the provider's name in the designated area.
7. Provide the provider's phone number to ensure effective communication regarding the referral.
8. Fill in the program manager's name and contact information, including their phone number next to their name.
9. Select the appropriate level of care by checking one of the options provided, such as outpatient, detox, or residential.
10. Ensure that the form is properly completed and ready for immediate faxing to the appropriate parties, with the numbers specified for Valley Health Plan and other involved departments.
11. Once all fields are filled out, save your changes before choosing to download, print, or share the completed form as needed.

Complete the Gateway Referral Form online today to facilitate efficient referrals.