Get Texas Referral Authorization Form .pdf - Parkland Community ...

This guide provides clear and concise instructions on how to complete the Texas Referral Authorization Form online. Ensuring accurate and complete submission of this form is essential for proper processing and authorization of referrals.

Follow the steps to fill out the form successfully.

1. Press the ‘Get Form’ button to access the Texas Referral Authorization Form. This will open the form in an editable format, allowing you to fill it out online.
2. Complete the health plan information by entering the health plan name and date. Make sure to also include the health plan fax number.
3. Provide the patient's information including their name, date of birth, sex, phone number, member ID number, and optional social security number.
4. In the 'Referred By' section, record the referring physician's name, provider number, and indicate whether they are a primary care provider, specialist, or associated with a hospital.
5. In the 'Referred To' section, input the name of the provider or facility to whom the referral is being made. Specify both the requested start and end dates for the referral.
6. Indicate the diagnosis using ICD-9 or DSM4 codes and provide the scope of the referral by selecting among consultation, diagnostic testing, or follow-up.
7. For specific services requested, detail the specialty type and provider or facility number, along with the appropriate contact information.
8. Indicate the referral location by selecting one of the options such as office, outpatient facility, or inpatient. Include the date of service if applicable.
9. Provide comments or clinical history that may be relevant to the referral, ensuring all pertinent information is included.
10. Have the referring physician sign the form in the designated area to certify its accuracy.
11. Once completed, you can save your changes, download, print, or share the form as needed.

Complete your Texas Referral Authorization Form online today for seamless processing.