Print Form Selffundedhealthplan SHORTREFERRALFORMThirdpartyAdministrator:Keenan&Associates ContractedHealthplan:AnthemBlueCross (TobeusedonlyforreferralswithinPrimeProviderNetwork,whenthe.
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How to fill out the Short Referral Form - Keenan online
Filling out the Short Referral Form - Keenan is an essential step in streamlining the referral process for healthcare services. This guide provides clear and supportive instructions to help you complete the form efficiently and accurately.
Follow the steps to complete the form with ease.
- Press the ‘Get Form’ button to acquire the necessary form and access it in the viewer.
- In the first section, fill in the patient name and date of birth (DOB). Ensure all spelling is accurate to avoid any delays.
- Provide the patient's address, including city, state, and zip code. This information is crucial for correspondence.
- Select the appropriate health plan option by marking either PPO or EPO.
- Enter the patient's phone number for contact purposes.
- Indicate the hospital of employment and the patient's ID number. This helps link the referral to the individual's health records.
- Detail the eligibility verification by mentioning the name or details of the individual or department that verified eligibility.
- Fill in the names of the primary care physician (PCP) and referring physician. Accurate information here supports continuity of care.
- Record the name of the provider or institution to which the patient is being referred, including the place of service and address when available.
- Specify the expected date of service, which is valid for 45 days from the authorization date you enter below.
- Provide a detailed diagnosis that accurately describes the patient's condition.
- List the services requested by the referring physician to ensure all needs are clearly communicated.
- If necessary, add reasons or notes from the referring physician to provide context or additional information.
- The referring physician must sign the form and enter the date to validate the referral.
- If needed, document any notes from the medical director or utilization review department.
- Finally, submit the completed form to the respective hospital administration, along with a copy to Prime Healthcare Services, Inc., using the provided contact details for mailing or faxing.
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