Get Referral Form - Passport

Filling out the Referral Form - Passport online is a straightforward process designed to ensure that members receive the necessary referrals from their primary care provider (PCP) to participating specialists. This guide will assist you through each section of the form to ensure accurate and efficient completion.

Follow the steps to fill out your Referral Form - Passport online:

1. Press the ‘Get Form’ button to acquire the Referral Form - Passport and open it in your preferred editor.
2. Begin by entering the Member ID#, followed by the member's last name and first name, ensuring correct spelling for all fields.
3. Input the member’s date of birth and phone number. If applicable, fill in the alternative last name and first name of the parent or guardian, along with their phone number.
4. Provide the PCP group name and the PCP group ID number to specify the healthcare provider associated with the referral.
5. In the section marked ‘This member is being referred to,’ enter the referred provider's name and ID number. Include their specialty type for accurate referral.
6. Complete the street address, city, and zip code of the referred provider to ensure correct location details.
7. In the next fields, detail the diagnosis along with the corresponding ICD-10 code, listing all relevant diagnoses available.
8. Indicate if this referral is related to an EPSDT screen by selecting 'Yes' or 'No' as appropriate.
9. The PCP must check one box under the referral type, indicating the nature of the referral and the number of visits approved.
10. Ensure the authorizing signature and date are clearly marked to validate the referral. Include any additional notes that may be necessary.
11. Once the form is completely filled, save changes, and options will be available to download, print, or share the form with relevant parties.

Complete your Referral Form - Passport online today for seamless healthcare access.