Get Managed Care Referral Form

This guide provides step-by-step instructions on how to fill out the Managed Care Referral Form online. By following these clear directions, you can ensure your form is completed accurately and effectively.

Follow the steps to successfully complete your Managed Care Referral Form

1. Click the ‘Get Form’ button to access the Managed Care Referral Form and open it in your preferred document editor.
2. Fill in the patient information section. Enter the patient's last name, first name, patient ID number, and date of birth in the specified format. Ensure accuracy as this information is critical for processing.
3. Complete the policy holder details. Provide the last name, first name, and middle initial (if applicable) of the policy holder in the corresponding fields.
4. Provide the referring physician information. Enter the provider's last name, first name, service address, Empire Provider ID or NPI, and telephone number.
5. Fill in the specialist information. Include the specialist's last name, first name, service address, Empire Provider ID or NPI, and telephone number.
6. Enter authorization information. Specify the number of visits, service start date, and service end date. Remember that referrals are valid for 90 days from the service start date.
7. Describe the referral reason, remarks, or limitations in the designated section. Be as clear and detailed as possible to provide necessary context.
8. Once all fields are completed, review the form carefully for accuracy and completeness.
9. Finalize your submission by saving changes, downloading, printing, or sharing the completed form, depending on your needs.

Complete your Managed Care Referral Form online today for a seamless healthcare experience.