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....
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How to fill out the Partnership Raf Form online
This guide provides a clear, step-by-step process for users to complete the Partnership Raf Form online. It is designed to help you navigate each section of the form effectively, ensuring that you provide accurate and complete information.
Follow the steps to successfully complete the Partnership Raf Form.
- Press the ‘Get Form’ button to acquire the Partnership Raf Form and open it in your preferred digital editor.
- Begin filling out the form by entering the member’s name in the designated field. Make sure the name matches the official documents for verification purposes.
- Provide the member's date of birth in the specified format. This information is crucial for identity verification.
- Enter the member's ID number as shown on their health plan documents to ensure correct processing.
- Fill in the member's address, including city and zip code. Accurate information will aid in communication and follow-up.
- Record the member's phone number, ensuring it is current and reachable for any necessary follow-ups.
- Indicate the services requested by selecting the appropriate boxes, such as 'Consult and/or Continuing Care.'
- Document the reason for referral and any relevant medical history, including copies of lab reports and imaging studies.
- Complete the clinician signature and print name fields, affirming that all information provided is true and accurate.
- Finalize the form by reviewing all entries for accuracy. Save your changes before downloading, printing, or sharing the form as needed.
Complete your Partnership Raf Form online today to streamline your referral process.
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Get answers to your most pressing questions about US Legal Forms API.
Is partnership health plan the same as Medi-Cal?
Partnership HealthPlan of California is a non-profit community based health care organization that contracts with the State to administer Medi-Cal benefits through local care providers to ensure Medi-Cal recipients have access to high-quality comprehensive cost-effective health care.
What is a eraf form?
ERAF is a mechanism; enacted in July of 1992 by the State Legislature to shift local tax revenues from cities, counties, and special districts to a State controlled Education Revenue Augmentation Fund. The state uses this fund to reduce its obligation to the schools.
What is a RAF request?
Referral Authorization Form (RAF) process: is defined as the process by which the primary care provider (PCP) submits a request to Partnership HealthPlan of California (PHC) to refer a PHC enrollee to a specialist for evaluation and/or treatment.
What is a RAF authorization?
A RAF is a referral form used by a Primary Care Provider (PCP) to carry out his/her case management role. It is to be used to refer assigned members for medically necessary services not generally provided by the PCP. Each RAF can only be used once and should contain diagnostic and treatment orders for only one patient.
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