Get Referral Form - Freedom Health

This guide provides clear and supportive instructions on filling out the REFERRAL FORM - Freedom Health online. By following these steps, users can ensure that their referrals are processed smoothly and efficiently.

Follow the steps to complete your referral form accurately.

1. Click the ‘Get Form’ button to access the REFERRAL FORM and open it in your document editor.
2. Fill in the 'Date' field with the current date to ensure your referral is timely.
3. Provide member information, including 'Referral Begin Date' and 'End Date'. If left blank, these dates will default to 90 days.
4. In the 'Referring Physician Information' section, enter the name, date of birth, ID number, and contact details (phone and fax) for the referring physician.
5. Identify the provider to whom the patient is being referred by checking the appropriate box (Physician, Radiology Center, Orthotics & Prosthetics under $500, or Therapy), and fill in their contact details including name, phone, fax, and address.
6. Fill in the Tax ID number for the referred provider if available.
7. Provide the relevant ICD-9 code and description for the condition being referred.
8. Select the number of office visits required, and check applicable services needed (e.g., Office Visit, Physical Therapy, Occupational Therapy, Speech Therapy). Provide the corresponding codes and descriptions as needed.
9. If applicable, complete the 'Facility' section, including the name and contact details of the ambulatory surgery center, ensuring it is a participating provider.
10. In the comments section, add any additional codes or relevant information that may assist in processing the referral.
11. Review the completed form for accuracy and ensure all required fields are filled out.
12. Once the form is complete, you can save your changes, download, print, or share the form as needed.

Complete your REFERRAL FORM - Freedom Health online today to ensure timely processing of your referrals.