Get Passport Referral Form

The Passport Referral Form is an important document used for referring a member from a primary care provider (PCP) to a specialist or an urgent care center. This guide provides clear, step-by-step instructions on how to fill out the form accurately to ensure a smooth referral process.

Follow the steps to complete the Passport Referral Form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill in the member's identification details. Start with the Member ID#, last name, first name, and date of birth. Ensure this information is accurate to avoid any processing issues.
3. Enter the member's contact information, including their phone number. Additionally, if applicable, provide information for an alternate name and phone number of a parent or guardian.
4. Specify the PCP group name and PCP group ID number. This helps in identifying the member's primary care provider.
5. Complete the referral section by providing the name and ID number of the referred provider. Additionally, indicate the specialty type and provide the provider's street address, city, and zip code.
6. Input the diagnosis and corresponding ICD-9 code. It is crucial to include all relevant diagnoses available at the time of referral.
7. Indicate whether this referral is related to an EPSDT screen by selecting 'Yes' or 'No'.
8. The PCP must check the appropriate referral type based on the nature of the consultation, diagnostic studies, and treatment. Choose from options such as unlimited visits or a specific number of visits approved.
9. Sign and date the form to authorize the referral. This indicates acknowledgment of the referral terms and conditions.
10. Once all fields are completed, save your changes, and download or print the form as needed. Make sure to share a copy with the specialist and the member.

Complete your Passport Referral Form online today for efficient processing.