Get Accountable Health Care Ipa Direct Referral Form 3-2017 V2

Filling out the Accountable Health Care IPA Direct Referral Form 3-2017 V2 online streamlines the process of seeking specialist care for patients. This guide provides step-by-step instructions to ensure accurate completion of the form for effective patient referrals.

Follow the steps to successfully complete your referral form online.

1. Click the 'Get Form' button to acquire the Direct Referral Form. This will allow you to access the document in a suitable online format for your convenience.
2. Begin by filling out the patient information section. Enter the patient's full name, date of birth, member ID, health plan, and ICD-10 code, along with the diagnosis. Ensure all details are accurate to prevent any issues with the referral.
3. Next, proceed to the contracted provider/facility section. Select the appropriate specialist from the list provided within the form. This ensures that the referral is valid and that services will be covered.
4. In the provider section, the primary care provider’s details must be included. This includes the name and signature of the provider, ensuring that the referral is approved before being presented to the specialist.
5. Sign and date the statement indicating the patient’s or guardian's understanding of member eligibility. This acknowledgment confirms that the individual is aware of their responsibility concerning service eligibility.
6. Select the appropriate exam types required for the referral from the provided list. Indicate the specific procedures and any pertinent details, ensuring clarity for the specialist.
7. Once the form is completely filled out, review all sections for accuracy and completeness. Users can save changes to the form in the online editor.
8. Finally, users can download, print, or share the completed form as required. This allows for easy distribution to the patient and the specialist's office.

Complete your referral forms online today for a smoother healthcare experience.