Get Referral Fax Form - Uhcprovider.com

Filling out the Referral Fax Form for UnitedHealthcare Navigate plans is a straightforward process that ensures timely and effective communication of referrals. This guide will walk you through each section of the form, providing clear instructions to assist in completing it accurately and effectively.

Follow the steps to complete your referral form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member's name, ensuring to include their last name, first name, and middle initial in the designated fields.
3. Input the member's ID number in the provided field, ensuring accuracy to avoid processing delays.
4. Fill in the member's phone number, including the area code, in the section labeled 'Phone.'
5. Provide the member's date of birth in the MM/DD/YYYY format within the appropriate field.
6. Enter the complete address of the member, including street, city, state, and zip code.
7. Next, provide the referring primary care physician's information by entering their name, tax ID number, address, and phone number.
8. In the specialist/rendering physician section, enter the specialist's name, specialty, tax ID number, address, and phone number.
9. Indicate the service requested by selecting either a routine referral or a standing referral.
10. List the diagnosis with code, ensuring to include at least one and not more than two codes as specified in the instructions.
11. Specify the number of visits that the referral will cover, noting that if this field is left blank, one visit is assumed.
12. Provide the dates for the routine service start and end, or for the standing referral start date as applicable.
13. Finally, ensure the form is signed by the referring primary care physician, and include today’s date in the required space.
14. Save any changes you made, and proceed to download, print, or share the completed form as necessary.

Complete your Referral Fax Form online today for efficient processing.