Get Fax: (810)733-9647

Filling out the Fax: (810)733-9647 provider referral form for pre-authorization can be straightforward. This guide will provide you with step-by-step instructions to help you complete the form online efficiently.

Follow the steps to complete the provider referral form request

1. Click ‘Get Form’ button to access the form and open it in your browser.
2. Enter the member's information by filling out the 'Member First Name', 'Member Last Name', and 'DOB' fields.
3. Provide the ordering provider's information, including 'Name', 'Address', 'Phone', 'Fax', and 'Office Contact Name'.
4. Indicate the member's plan by selecting from the options such as 'Medicaid', 'Healthy Michigan', or 'Commercial'.
5. Fill in the 'Date of Request' and 'Member ID', as well as the 'Specialty', 'City', and 'Zip' fields.
6. Input the information for the referral destination, including the 'Name', 'Address', 'Phone', and 'Office Contact Name' of the individual the member is being referred to.
7. Select the required service by checking the appropriate box, and fill in additional details such as 'Specialty', 'Physician Name', and any notes relevant to the request.
8. If applicable, enter the details for outpatient or inpatient procedures, including facility names, performing surgeon names, dates of procedures, and necessary billing NPI information.
9. For therapy services, indicate the 'ICD-10' codes and specify the number of visits required for PT, OT, and ST.
10. Complete any sections for home health care or hospice services, including relevant ICD-10 codes and the number of visits.
11. Once you have filled out all necessary sections, review your information for accuracy and completeness.
12. After reviewing, save your changes, download the form, print, or share it as needed.

Complete your documents online with ease and efficiency.