Get Chita Standard Referral Form - Provider Ghc

Filling out the CHITA Standard Referral Form - Provider Ghc online can streamline the referral process for patients. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete the CHITA Standard Referral Form online.

1. Use the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. In the 'Referral From' section, fill in the provider's tax ID number, last name, first name, UPIN, middle initial, and the name of the patient's primary care provider if it is different from the referring provider.
3. Provide the contact person's name and telephone number for further communications.
4. In the 'Patient Information' section, select the patient's gender, and fill in their first and last name, member ID number, contact phone, date of birth (MM/DD/YYYY), and preferred language if it is not English. Indicate if an interpreter is required.
5. Enter the last name, first name, and middle initial of the parent or legal guardian, along with their contact phone.
6. Complete the subscriber’s last name, first name, middle initial, and ID number.
7. Indicate the provider network, primary health plan, product name, and the plan's assigned number. If there is secondary coverage, include that information as well.
8. In the 'Referral To' section, provide the name of the provider you are referring the patient to, their telephone number, specialty, and the number of requested visits.
9. Specify the referral's expiration by indicating how many months it is good for from the referral date.
10. Select the action requested, including options like 'Routine,' 'Urgent,' or 'Evaluate and Treat.' Indicate whether the patient should call to schedule an appointment or if they will be contacted to schedule.
11. Fill out the reason for referral, including any restrictions and the ICD9 code, if applicable.
12. Complete any instructions, procedures, and itemized services that apply. Include details on office procedures, home health, therapies, etc.
13. Sign and date the form in the reserved area for provider office use, adding any necessary clinical findings or documentation.
14. Once you have completed all sections, save your changes, and choose to download, print, or share the form as needed.

Complete your CHITA Standard Referral Form online today for an efficient referral process.