Get Referral Request Form

Filling out the Referral Request Form online can streamline your referral process and ensure you receive timely care. This guide will provide you with step-by-step instructions to complete the form accurately.

Follow the steps to fill out your Referral Request Form online

1. Click ‘Get Form’ button to retrieve the Referral Request Form and open it in your preferred editor.
2. Enter the date of your request in the designated field. This is important for tracking your referral processing time.
3. Input the date of appointment as requested. Ensure this date aligns with your scheduled visit.
4. Indicate if this is an emergency appointment by selecting 'Yes' or 'No' in the provided options.
5. Provide the patient’s name in the appropriate field. Ensure spelling is correct for accurate identification.
6. Fill in the patient’s date of birth to confirm identity and eligibility.
7. Enter the patient’s Aetna ID number. Double-check this number to avoid processing delays.
8. Specify if the patient is the subscriber by selecting 'Yes' or 'No.' This detail is critical for claims processing.
9. Write the specialist's name (first and last) who will be seeing the patient.
10. Input the specialist’s NPI number in the required field, as this is necessary for referral processing.
11. Include the specialist’s Aetna ID number which is also necessary for processing.
12. Provide the specialist's phone number to facilitate communication regarding the referral.
13. Enter the specialist’s fax number if applicable, which may be required for sending documents.
14. Clarify the reason for the visit in the designated section. Be concise and specific to ensure the referral is appropriate.
15. Indicate how many visits you expect to need over the next six months.
16. Review all entered information for accuracy. Once confirmed, you can save changes, download the form, print a copy, or share it as needed.

Complete your Referral Request Form online today for a smoother referral experience.