Get Ucare Restricted Recipient Form

Filling out the Ucare Restricted Recipient Form accurately is essential for ensuring that the medical referrals are processed efficiently. This guide will assist you with a clear and supportive approach to navigate the form’s sections and complete it online.

Follow the steps to complete the form seamlessly.

1. Click the ‘Get Form’ button to retrieve the Ucare Restricted Recipient Form and open it in your preferred online editor.
2. In Section I, enter the recipient's name and date of birth. Follow by filling in the primary physician's name, PMI number, and provider identification number. Complete the street address, phone number, city, state, and zip code of the primary physician.
3. Move to Section II to provide referral information. Input the name, specialty, and identification number of the provider you are referring to. Fill out the street address, clinic name, along with its identification number, city, state, and zip code, and their phone number.
4. Detail the reason for the referral and include the appropriate ICD 9 or 10 code. Indicate if the referral is for a visit only or if the provider may prescribe controlled medications if necessary, and specify the start and end dates for the referral.
5. Have the referring provider sign the form and print their name along with the date. Make sure all fields are completed accurately.
6. After reviewing the completed form for accuracy, it must be sent to the Ucare Restricted Recipient fax line at 612-884-2316 as soon as possible. Ensure the document is saved securely for your records.

Complete the Ucare Restricted Recipient Form online today to facilitate timely medical referrals.