Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the chosen document editor.
2. Enter the health plan name in the designated field. Make sure to provide accurate details as printed on any official documentation.
3. Fill in the date of the request and the health plan fax number, if applicable.
4. Complete the patient information section, including the patient's date of birth, first name, middle initial, sex, phone number, member ID, and Social Security number.
5. Indicate whether the referral is routine, urgent, emergency, out of network, a revised referral, or notification only.
6. Specify the requested start and end dates for the referral.
7. Fill in the patient's last name and include any applicable diagnosis codes in the ICD-9/DSM4/Diagnosis section or write the description if codes are unknown.
8. Input the referred by physician's name, including last name, first name, and middle initial. Check the appropriate box to indicate their role (e.g., PCP, SCP, Hospital).
9. Provide the referring physician's provider number and fax number, along with their contact name and phone number.
10. Outline the specific services requested and adhere to the certification/authorization guidelines provided. Include the number of visits if necessary.
11. Complete the referred to section by entering the provider's name, specialty type, fax number, phone number, and city, along with expected service dates.
12. Detail the referred to location by selecting the appropriate service type, like office, outpatient facility, hospital, etc.
13. Complete any additional information, including comments or clinical history pertinent to the referral.
14. The referring physician must sign the form, affirming the information is accurate and complete.
15. Once the form is filled out, users can choose to save changes, download, print, or share the form as needed.

Complete your forms online to ensure accurate and efficient processing of your health care referrals.