Get Prior Authorization And Referral Request Form - Community Health ...

This guide provides users with a clear and structured approach to completing the Prior Authorization And Referral Request Form for Community Health online. By following these instructions, users can ensure they provide the necessary information accurately and efficiently.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to obtain the form and open it in your designated editor.
2. In the first section, provide details about the patient who needs the service. Fill out the patient's name, date of birth (DOB), address, phone number, health plan, and member number.
3. Next, indicate the requesting provider's information. Print the provider's name, clinic, office contact, date, and phone number in the second section.
4. For the third section, specify what services the patient needs. Check the appropriate service requested, such as consultation, office visit, or inpatient admission, and provide additional details as required.
5. In the fourth section, list the facility or provider to whom the patient is being referred. Include the name, phone number, address, and fax number of the referral source.
6. In the final section, explain the reason for the referral. Include the diagnosis (ICD code) or a description of the patient's condition, and attach any necessary clinical notes. Make sure to be thorough in your explanation.
7. After completing all required sections, review the form for completeness and legibility. Once verified, save changes, download, or print the form for submission.

Start your request by filling out the Prior Authorization And Referral Request Form online today.