Get Referral Consultation Request Form - Central California Alliance For ... - Ccah-alliance

Filling out the Referral Consultation Request Form is an important step in ensuring your patient receives the necessary care. This guide will provide clear instructions on each section of the form to help you complete it effectively and accurately.

Follow the steps to complete the Referral Consultation Request Form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by completing the 'Member Information' section. Fill in the member’s name, date of birth, and member ID. Ensure that all information is accurate, as it is essential for claims processing.
3. Next, fill out the 'Servicing Provider Information' section. Provide the name, address, phone number, and NPI (if known) of the servicing provider to whom the referral is being made.
4. Indicate the member's sex by selecting the appropriate option, either 'Male' or 'Female'. If the member is a child with a medically eligible condition, ensure that the referral is directed to a CCS paneled provider and that the local CCS office is notified.
5. In the 'Referral Information' section, write down the reason for the referral, including a detailed description of the chief complaint. Use clear language and be as specific as possible.
6. If applicable, enter the diagnosis code and description in the designated fields. This information helps in the processing of the referral.
7. Select the type of consultation required by checking the appropriate box. You can choose either 'Consultation Only' or 'Consultation with Follow-up Visits' and specify the number of follow-up visits if necessary.
8. Fill in the validity period of the referral by indicating the start and end dates. Remember, the referral cannot exceed one year and is generally valid for 90 days from the date of signature unless specified otherwise.
9. Complete the 'Primary Care Physician Information' section. Provide your NPI, name, phone number, and fax details. Make sure to include your signature and the date.
10. Once all sections are completed, review the form for accuracy. You can now save your changes, download, print, or share the form as necessary.

Complete the Referral Consultation Request Form online to ensure timely and proper healthcare for your patients.