Get Referral Form - Providers - Prestige Health Choice. Referral Form

The Referral Form - Providers - Prestige Health Choice is an essential document used to ensure seamless healthcare access for members. This guide provides clear, step-by-step instructions to help users effectively complete the form, streamlining their experience in securing necessary referrals.

Follow the steps to fill out the Referral Form accurately and efficiently.

1. Click the ‘Get Form’ button to obtain the Referral Form and open it in your preferred document editor.
2. Begin by filling in the member information section. Enter the member number, last name, first name, date of birth, gender, and phone number.
3. Proceed to the provider information section and provide the primary care physician's name, PCP number, county, phone number, and fax number.
4. In the specialist information section, fill out the county, type (specialty), specialist provider name, provider phone number, and provider address.
5. Enter the diagnosis code in the ICD-9 section, noting that ICD-10 codes are to be used after October 1, 2014. Specify if the evaluation is for evaluation only or evaluation plus visit.
6. Indicate the timeframe for the request by selecting from the options available: 30 days, 60 days, 90 days, or 1 year.
7. Fill out the background description to provide context for the referral and describe the service requested, along with the reason for the referral.
8. Once all sections are completed, ensure to review your information for accuracy. You can then save changes, download, print, or share the form as needed.

Start filling out your Referral Form online today for efficient healthcare access.