Get Par-40727-patient-authorization-and-referral-form.pdf

Filling out the PAR-40727-Patient-Authorization-and-Referral-Form online is a straightforward process designed to facilitate patient care. This guide provides clear instructions to help you complete the form accurately and effectively.

Follow the steps to successfully fill out the form online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin with the Patient section. Enter the patient's first name, middle initial, last name, and date of birth. Fill in the address fields, including street address, city, state, and ZIP code. Include the primary phone number and an alternate phone number if available.
3. Provide insurance information by entering the primary insurer's name and phone number. Fill in the subscriber's name and subscriber ID. Include the RxBIN, RxPCN, and RxGrp numbers. If applicable, attach copies of the front and back of the insurance cards.
4. In the Healthcare Professional section, input the prescriber’s name, specialty, and group or hospital. Fill in the street address, city, state, ZIP code, and the prescriber’s contact information, including phone and fax numbers.
5. Specify the ICD-10 codes relevant to the patient's treatment. Indicate how the patient intends to obtain by checking the appropriate options provided.
6. Answer the question regarding sending a benefits verification report to the healthcare provider’s office by selecting 'Yes' or 'No.'
7. For minors, confirm if they have the capacity to consent for treatment by selecting the appropriate statement. Include the prescriber’s signature and date.
8. Review all filled information for accuracy. Make any necessary corrections before finalizing the form.
9. Once completed, you can download, print, or share the form as needed, ensuring to save your changes.

Take the next step in managing your healthcare by completing the PAR-40727 form online today.