Get Blue Cross Blue Shield Of Michigan - U.p. Blue Out-of-state Referral Preauthorization Form. U.p

This guide provides clear instructions on how to complete the Blue Cross Blue Shield Of Michigan - U.P. Blue Out-of-State Referral Preauthorization Form. By following the steps outlined below, users can efficiently fill out the necessary information to seek approval for out-of-state referrals.

Follow the steps to complete your referral form accurately.

1. Click ‘Get Form’ button to acquire the form and open it for editing.
2. Begin by filling out the patient information section. Enter the patient's full name, contract number, and group number accurately.
3. Next, complete the referring physician information section. Provide the referring physician's name, specialty, phone number, and fax number.
4. In the out-of-state physician/laboratory/facility information section, include the name, specialty, phone number, fax number, address, city, state, and zip code of the out-of-state provider.
5. Proceed to the reason for referral section. Indicate the services being requested and the justification for referring out-of-state, selecting from: no in-state provider available, in-state provider unable to schedule timely, or other.
6. Finish by signing and dating the form in the referring physician signature section.
7. Once you have filled out the form completely, save your changes. You can then download, print, or share the form as needed.

Complete your documents online today for a smoother referral process.