Follow the steps to fill out the referral/authorization form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide the health plan information by entering the health plan name and the date. Ensure accuracy, as this affects eligibility and benefits.
3. Fill in the patient information section, including the patient's full name, date of birth, sex, and contact number. If available, include the member ID and optional social security number.
4. Complete the referred by section by entering the referring physician's name and provider number. Select the type of referral from the provided options such as PCP, SCP, or hospital.
5. Indicate the urgency of the referral by checking the relevant box for routine, urgent, emergency, out of network, revised referral, or notification only.
6. Specify the requested start and end dates for the referral and note the appropriate ICD-9/DSM4 diagnosis.
7. Select the scope of referral by checking the services required, such as consultation, diagnostic testing, or follow-up, and enter the number of visits needed.
8. List the specific services requested and complete the referred to section with the provider's name, specialty type, and contact information.
9. Indicate the location of the referral, choosing from options like office, outpatient facility, inpatient, or other, and provide the date of service.
10. In the comments/clinical history section, include any relevant clinical details required for emergency, therapy, and outpatient services.
11. The physician must sign the form and provide the date to finalize it.

Complete your TX Driscoll Children's Hospital Referral/Authorization Form online today for a smooth referral process.