Get Out-of-network Referral Request Form - Siho - Siho

Filling out the Out-of-Network Referral Request Form - SIHO - Siho online is an essential process for users seeking referrals to out-of-network providers. This guide provides clear and supportive instructions to help you navigate the completion of the form with confidence.

Follow the steps to effectively complete your referral request form.

1. Press the ‘Get Form’ button to access and open the Out-of-Network Referral Request Form - SIHO - Siho in your digital environment.
2. Enter the patient’s name in the designated field, ensuring accuracy for proper identification.
3. Fill in the patient's date of birth using the format provided, including the day, month, and year.
4. Provide the patient ID number in the corresponding section to link the referral with the patient's records.
5. Detail the diagnosis, including any relevant ICD9 codes that support the referral request.
6. Indicate the anticipated date of service in the specified date field.
7. Input the requesting physician's name and their NPI/TIN in the respective areas.
8. Include the contact name along with the phone number and fax number for further communication.
9. Provide the complete address for the requesting physician to ensure proper correspondence.
10. Enter the vendor or facility name and the referred-to provider name in the relevant fields.
11. Complete the NPI/TIN for the facility or provider along with their phone and fax numbers.
12. Fill in the address for the vendor or facility.
13. If known, complete the date of the appointment and date of surgery fields.
14. Specify the requested number of visits and date range as needed for your service.
15. Indicate the fax number where approval or denial should be sent.
16. Add any additional comments or notes in the comments section, ensuring that all necessary information is conveyed.
17. Once all fields are completed, you can save your changes, download the form for record-keeping, print it for distribution, or share it as required.

Complete your Out-of-Network Referral Request Form - SIHO - Siho online to ensure timely processing of your referral.