Get Referral Authorization Form - Hpsm - Hpsm

Filling out the Referral Authorization Form for HPSM is an important step in facilitating your healthcare needs. This guide provides you with comprehensive instructions to ensure that you complete the form accurately and efficiently online.

Follow the steps to fill out the form online with ease.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Part I, which is designated for the referring primary care provider (PCP). Review the program options and check the appropriate box for Medi-Cal, Healthy Families, Healthy Kids, or HeathWorx.
3. Enter today’s date, the PCP provider number, and the PCP’s contact information, including phone and fax numbers.
4. Fill in the PCP's name and signature, followed by the patient’s information, including their name, date of birth, and member ID number.
5. Complete the patient's address and phone numbers. Choose the optional referral type by checking either ‘Consult Only’ or ‘Standing Referral for 1 Year’ if applicable.
6. Proceed to the HPSM use only section. Ensure to leave spaces for the date of receipt from the PCP, the diagnosis, ICD-9 code, reason for referral, and authorization number.
7. In the final part of the form, make sure to include the specialist's name, NPI number, and their contact details, including address, phone number, and fax number.
8. After completing all necessary fields, you can save your changes, download the document, and either print or share the completed form as needed.

Complete your Referral Authorization Form online today to ensure timely healthcare access.