Follow the steps to fill out the Ucare Restricted Recipient Form successfully.

1. Click ‘Get Form’ button to access the Ucare Restricted Recipient Form and open it in your preferred editing tool.
2. In Section I, fill out the primary physician details. Enter the date, recipient's name, date of birth, and your primary physician information including PMI number, provider I.D. number, street address, phone number, city, state, and zip code.
3. In Section II, provide the referral information. Include the first and last name of the person you are referring, their specialty, I.D. number, street address, clinic name, and corresponding I.D. number. Additionally, fill out the city, state, zip code, and phone number for the referral.
4. Detail the reason for the referral and include the ICD 9 code. Specify whether this referral is for a visit only or if the provider may prescribe controlled medications, and fill in the start and end dates for these actions.
5. Provide your signature as the referring provider and print your name below the signature. Finally, include the date to confirm when the form was signed.
6. Prepare to send the completed form by faxing it to the Ucare Restricted Recipient fax line at 612‐884‐2316 promptly after completion. If you have any questions, contact the Care Coordinator at 612‐676‐3397.
7. Once you've completed and sent the form, ensure you save any changes, download a copy for your records, or print it out as necessary.

Start completing your Ucare Restricted Recipient Form online today to ensure a smooth referral process.