Get Pad Referral Form V2 - Passport

This guide provides step-by-step instructions for completing the PAD Referral Form V2 - Passport online. It is designed to help users understand each section and field of the form, ensuring a smooth and efficient process.

Follow the steps to fill out the PAD Referral Form V2 - Passport online.

1. Press the ‘Get Form’ button to obtain the PAD Referral Form V2 - Passport and open it in your preferred editor.
2. Begin by entering the member ID number in the designated field. This is a required field.
3. Next, provide the name of the Primary Care Provider (PCP) or the name of the PCP group in the appropriate section.
4. Enter the member’s last name and first name as required fields.
5. Fill in the member’s date of birth in the specified format.
6. Input the PCP or PCP group ID number, which is another required field.
7. In the ‘Referred to’ section, specify the name of the facility or group providing the referral. Use the facility name or ID if applicable.
8. Complete the ‘Specialty type’ field with the relevant specialty for the referral.
9. Provide the street address, city, and zip code of the referred provider.
10. Fill in the diagnosis code(s) which is required to ensure proper documentation of the referral.
11. The PCP must check one of the options for the referral duration: unlimited or a limited number of visits, along with the corresponding visit numbers.
12. If a date range is necessary, include it in the designated fields.
13. Complete the signature field along with the date to validate the form.
14. Finally, ensure you send a copy of the completed form to Passport Advantage via the designated fax number or email.

Complete your PAD Referral Form V2 - Passport online to streamline your referral process.