Get Out Of Network Referral Request - Northwest Physicians Network - Npnwa

Filling out the OUT OF NETWORK Referral Request form is a straightforward process that ensures your medical requests are handled appropriately. This guide will walk you through each section of the form, providing clear instructions to help you submit your request successfully.

Follow the steps to fill out the OUT OF NETWORK Referral Request form effectively.

1. Press the ‘Get Form’ button to access the referral request document and open it in your preferred editing program.
2. In the 'Patient Information' section, complete the fields with the patient’s name, date of birth, member ID, and phone number to ensure accurate identification.
3. Identify the primary care provider by entering their name and contact details, as well as the specialist provider or facility information in the designated fields.
4. Specify the date the referral was made and ensure that you select the appropriate options under 'Patient Referred For,' checking all relevant services that will require authorization.
5. Clearly document the diagnosis and applicable ICD-9 codes in the respective fields to provide necessary medical context for the referral.
6. The requesting provider should sign in the provided signature section to validate the request, confirming that all information is accurate and complete.
7. If applicable, list any additional required services and include their details, ensuring all treatments or studies needing prior authorization are accounted for.
8. Once all sections are filled out, you have the option to save changes, download the completed form, or print it directly for submission.

Submit your OUT OF NETWORK Referral Request online to enhance your healthcare experience today.