Get Optumhealth Care Solutions Mtp Paper Referral Form 2007-2025

Filling out the OptumHealth Care Solutions MTP Paper Referral Form online is an essential part of notifying the organization of a transplant referral. This guide provides clear, step-by-step instructions to help users complete the form accurately and efficiently.

Follow the steps to accurately complete the referral form

1. Click ‘Get Form’ button to access the form and open it in your preferred document editor.
2. In section 1, fill in the referral information. Enter the date, your name as the referring case manager, along with your telephone number to ensure clear communication.
3. Proceed to section 2, which is optional. If applicable, provide benefit information such as deductible amounts, copay fees, out-of-pocket maximums, and lifetime maximums.
4. In section 3, enter the patient information. This includes the patient's name, group name, their relationship to the insured, group number, policy holder's name, subscriber ID, street address, phone number, city, state, date of birth, zip code, and social security number.
5. Also in section 3, provide additional details such as the member enrollment date, coverage effective through date, employer effective date, employment status, and dates for Medicare and Medicaid effectiveness, if applicable.
6. Fill out the eligibility section. Indicate whether COBRA applies, if the patient is disabled, and include the employer's phone number.
7. In section 4, enter claims information. Specify the claims mailing contact name, their phone number, fax number, and mailing address, including city, state, and zip code. Provide contact information for claims status, if necessary.
8. Next, provide medical information in section 4, including primary and related diagnoses, complete medical history, evaluation date, list date, facility name, admission date, the name of the current treatment facility, last date of service, transplant type, and dialysis start date.
9. Finally, provide details regarding the referring physician or contact person, including their name and telephone number.
10. Upon completing the form, review all the information for accuracy. Then, you can save the changes, download it, print it out, or share it as necessary.

Complete your OptumHealth Care Solutions MTP Paper Referral Form online today for a seamless referral process.