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Ver. 5.0Diabetic Prescription Referral Form PATIENT INFORMATION Name: DOB: Insurance: Insurance ID #: Address: Phone: Caregiver Name (if any): Caregiver Phone: Enroll patient into Diabetic Education.

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Medical Reviewer Signature (Circle Title: MD, DO, RN, LVN, Coordinator) Date Criteria utilized in making this decision is available upon request by calling IEHP (866) 725-4347. UPON ACCEPTANCE OF REFERRAL AND TREATMENT OF THE MEMBER, THE PHYSICIAN/PROVIDER AGREES TO ACCEPT IEHP CONTRACTED RATES.

For a regular referral, expect a letter from your medical group or IEHP within 2 days after a decision has been made. When the request is approved, call your Specialist to make an appointment.

To change your medical plan, call Health Care Options at 1-800-430-4263 (TTY 1-800-430-7077). Or you can complete a Medi-Cal Choice Form.

IEHP is committed to improving the coordination of healthcare benefits for members with both Medicare and Medi-Cal. These “dual eligibles” are low- income, and are over 65 or have a disability. They often struggle to get the care they need through multiple disconnected programs.

Medi-Cal is a no-cost or low-cost health coverage program. It provides health, dental and vision coverage to qualified low-income California residents. IEHP is the health plan for Medi-Cal recipients in San Bernardino County.

IEHP DualChoice will cover many of the Medicare and Medi-Cal benefits you get now, including: All Medicare covered services, doctors, hospitals, labs, and x-rays. You will have access to a Provider network that includes many of the same Providers as your current plan. Prescription drugs covered by Medicare.

Can I Get Medi-Cal if I Have Insurance? If you have private health insurance, you can still qualify for Medi-Cal. Members who already have insurance can add Medi-Cal coverage to their existing plan. Your provider will first bill your private insurance, and then Medi-Cal will pay for any additional services it covers.

IEHP is the health plan for Medi-Cal recipients in San Bernardino County. We are dedicated to providing our Members and local communities with optimal care and vibrant health.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232