Get Partnership Raf Form

RAF NUMBER PARTNERSHIP HEALTHPLAN OF CALIFORNIA 4665 Business Center Drive Fairfield CA 94534 Referral Authorization Form RAF 707 863-4133 or 800 863-4144 707 863-4118 FAX Member Name Referred to Date of Birth ID Address Member Phone City Zip Telephone Consults must be initiated 30 days of date below. Consultants should verify PCP Payment subject to member eligibility. Approval of consultation limited to covered benefits. The consultant name must be the same as that used to bill for these services. TO BE COMPLETED BY THE REFERRING CLINICIAN Services requested Consult and / or Continuing Care 2 months Please call me when you have seen patient. up to 12 mos. I would like to receive periodic status report. from date of issue Call me if procedures or admission planned* Is requested provider contracted with PHC. This referral is If Non-Contracted provider RAF must be approved by PHC before given to member. Urgent potentially life-threatening condition* Indicated important to health not life-threatening. Reason for referral Work-up and treatment to date Include copies of lab reports imaging studies etc* Questions I need answered Provisional Diagnosis Primary ICD-9 /Dx Date of Issue Clinician Signature Print Name Send consult report to City Phone Fax Final Report please check all that apply Typed consultation note will be sent to you. My medical record note will be sent to you. I will call you to discuss case. Patient was not seen as scheduled on PHC Determination Preliminary Report Approved Redirected to Contracted Provider Denied SignatureDate Plan Signature / Print Name Distribution Copies Consultant PCP PHC Date Seen Phone No* Fax No*. Consultants should verify PCP Payment subject to member eligibility. Approval of consultation limited to covered benefits. The consultant name must be the same as that used to bill for these services. TO BE COMPLETED BY THE REFERRING CLINICIAN Services requested Consult and / or Continuing Care 2 months Please call me when you have seen patient. The consultant name must be the same as that used to bill for these services. TO BE COMPLETED BY THE REFERRING CLINICIAN Services requested Consult and / or Continuing Care 2 months Please call me when you have seen patient. up to 12 mos. I would like to receive periodic status report. from date of issue Call me if procedures or admission planned* Is requested provider contracted with PHC. up to 12 mos. I would like to receive periodic status report. from date of issue Call me if procedures or admission planned* Is requested provider contracted with PHC. This referral is If Non-Contracted provider RAF must be approved by PHC before given to member. Urgent potentially life-threatening condition* Indicated important to health not life-threatening. This referral is If Non-Contracted provider RAF must be approved by PHC before given to member. Urgent potentially life-threatening condition* Indicated important to health not life-threatening. Reason for referral Work-up and treatment to date Include copies of lab reports imaging studies etc* Questions I need answered Provisional Diagnosis Primary ICD-9 /Dx Date of Issue Clinician Signature Print Name Send consult report to City Phone Fax Final Report please check all that apply Typed consultation note will be sent to you.