Get Texas Referral Authorization Form

Filling out the Texas Referral Authorization Form online can streamline the referral process, ensuring that all necessary information is accurately captured. This guide will walk you through each section of the form, providing step-by-step instructions for ease of completion.

Follow the steps to complete your Texas Referral Authorization Form.

1. Click ‘Get Form’ button to access the Texas Referral Authorization Form and open it in your preferred digital editor.
2. Begin by filling out the health plan information. Indicate the health plan name and date, along with the health plan fax number if applicable. Ensure that all details are accurate.
3. In the patient information section, enter the patient's full name, date of birth, gender, and phone number. Fill in the member ID and optional social security number as needed.
4. Next, complete the referring physician section. Provide the physician's full name, provider number, and indicate whether they are a primary care provider, specialist consultant, or hospital, as well as the urgency of the referral.
5. Enter the requested start and end dates for the referral and provide any applicable diagnosis codes and scope of referral settings. Indicate the number of visits required.
6. Specify the services requested by detailing the referred provider's name, specialty type, and contact information. Ensure that any required CPT/HCPCS codes are included, particularly for outpatient services.
7. Complete the specific services requested and confirm that they align with the member’s health plan guidelines. Include the location of the referred provider and the anticipated date of service.
8. In the comments section, provide any relevant clinical history or additional information for the referral, attaching any documents if necessary.
9. Finalize the form by signing and dating it in the physician's signature section, ensuring all required fields are completed.
10. Once you have filled in all sections, review the document for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete your Texas Referral Authorization Form online today for a smooth referral process.