Get Ma Unicare Provider Referral Request Form 2013-2025

Filling out the MA UniCare Provider Referral Request Form online can streamline the referral process for healthcare providers. This guide will provide clear, step-by-step instructions to ensure that you complete the form accurately.

Follow the steps to successfully complete the form.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Fill out the referring section by providing the specialty, phone number, and fax number of the referring provider. Include the practice name and address, then select the desired scheduling options, such as 'Urgent' or 'Routine Appointment.' Be as specific as possible.
3. In the type of referral section, indicate the referring provider's name, fax number, and specify the type of referral. Choose from options like evaluation consultation with treatment recommendations or specialist to specialist referral, making sure to send a copy to the primary care provider.
4. In the patient information section, enter the patient's full legal name, date of birth, and, if applicable, the name of the parent or guardian. Provide the preferred phone number and the best time to call.
5. Include any special patient considerations, insurance information, and the primary care provider's contact details in the respective fields.
6. Clearly state the reason for the referral alongside any comments or considerations related to the clinical question. Include relevant documents such as recent labs and imaging reports if needed.
7. Indicate whether the patient is aware of the reason for the referral by marking 'Yes' or 'No' and providing an explanation if they are not.
8. In the referral confirmation section, confirm whether the referral has been accepted and include details such as the appointment schedule, if applicable.
9. Finally, provide the name of the person completing the confirmation and the date of confirmation. Once all sections are filled out, you can save changes, download, print, or share the form as needed.

Complete your MA UniCare Provider Referral Request Form online today for efficient processing.