Get Banner Referral / Authorization Form - Banner Health Plans

Filling out the Banner Referral / Authorization Form correctly is essential for a smooth referral process to specialists. This guide will walk you through the necessary steps to complete the form online, ensuring all required information is accurately provided.

Follow the steps to accurately fill out the referral and authorization form

1. Click ‘Get Form’ button to access the referral/authorization form and open it in the editor.
2. Begin by entering the patient's full name, date of birth (DOB), and identification number (ID#) in the designated fields at the top of the form.
3. Provide information about the referral, including the name of the specialist and their contact information. Indicate the health plan associated with the referral.
4. Specify the place of service and the date of service (DOS). Check the appropriate box to indicate whether this is an inpatient or outpatient service.
5. Detail the diagnosis by including relevant ICD9 codes, and describe the specific services being requested, listing any associated CPT codes.
6. Add any additional information pertinent to the specialist, such as notes, labs, reports, or X-rays that will assist in preparing for the patient’s visit.
7. Fill in the referring doctor's name and their office contact information, ensuring all details are clearly stated.
8. Affix the provider's signature and the date, along with a contact phone number for follow-up.
9. Review all entries for accuracy and completeness. Once confirmed, you can save your changes, download the completed form, print it out, or share it digitally as needed.

Complete your Banner Referral / Authorization Form online today to ensure prompt processing.