REFERRAL FORM Claims submitted more than one (1) year after the date of service are not payable REFERRED TO FACILITY OR PROVIDER MEMBER INFORMATION MEMBER NO. FACILITY OR PROVIDER ADDRESS BIRTHDATE.
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How to fill out the Referral Form - Harbor Health Plan online
Filling out the Referral Form for Harbor Health Plan is a straightforward process that ensures timely authorization for required medical services. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.
Follow the steps to complete the Referral Form online.
- Press the ‘Get Form’ button to access the Referral Form and open it for editing.
- In the 'Member Information' section, enter the user's member number, birthdate, phone number, and address including city and zip code.
- Complete the 'Referred to Facility or Provider' section by entering the facility or provider's name and address details.
- Fill in the 'Referred By Primary Care Physician' section with the physician's last name, address, and contact information including phone and fax numbers.
- If applicable, provide information in the 'Other Insurance' section. Include the carrier's name, contract number, and contact details.
- In the 'Diagnosis' section, clearly identify and detail the treatment and/or services being authorized. Use both diagnosis and procedure codes as needed.
- For referrals concerning home care or therapy, fill in the 'Referral for Home Care' or 'Referral for Therapy' section, indicating the number of visits required.
- If durable medical equipment (DME) is requested, specify the items needed in the designated section.
- Review all entered information for accuracy. Once complete, you can save changes, download, print, or share the completed form as required.
Take action today and fill out your Referral Form online to ensure timely processing of your medical services.
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