Get Michigan Healthcare Referral Form

This guide provides step-by-step instructions on how to accurately complete the Michigan Healthcare Referral Form online. Whether you are a healthcare provider or a patient, understanding the components of this form is essential for ensuring proper referrals and continuity of care.

Follow the steps to complete the form online with ease.

1. Press the ‘Get Form’ button to access the Michigan Healthcare Referral Form and open it in the editor.
2. Enter the patient's name in the designated fields for 'First' and 'Last'.
3. Input the member identification number and suffix if applicable.
4. Indicate the primary care provider's name in the respective section.
5. Fill in the referral source's name and contact phone number.
6. Provide the date of birth for the patient and check off any applicable care types, such as if the referral is for an auto accident or worker's compensation.
7. Enter the tax identification number and plan assigned provider ID number for the referring provider.
8. In the 'Referred To' section, fill in the details of the healthcare provider to whom the patient is being referred.
9. Input the address of the referred provider, ensuring to include the street, city, state, and zip code.
10. Document the ICD-10 diagnosis code relevant to the referral.
11. Set the start and end dates for the referral, along with the location of service (provider office, outpatient hospital, or ER/UCC).
12. For any specific services requested, please check the appropriate boxes and specify the number of visits as needed.
13. If applicable, list any CPT codes for ambulatory surgery or other specific services requested.
14. Include any additional comments or notes if necessary.
15. Review all entered information for accuracy, then save your changes, download, print, or share the completed form.

Complete your Michigan Healthcare Referral Form online today for efficient management of healthcare referrals.