Get Memorialcare Referral Authorization Request Form 2016-2026

The MemorialCare Referral Authorization Request Form is essential for initiating the referral process for healthcare services. This guide provides clear and supportive instructions on how to fill out this form efficiently and accurately online.

Follow the steps to complete the MemorialCare Referral Authorization Request Form online

1. Press the ‘Get Form’ button to access the MemorialCare Referral Authorization Request Form and open it in your chosen editor.
2. Fill in the ‘Date of Request’ at the top of the form to indicate when the request is being made.
3. Select the appropriate request type by checking one of the three boxes: Routine, Urgent, or Emergent, based on the clinical need.
4. Provide the ‘Requesting Provider/Group Name’ and specialty to identify the healthcare provider making the referral.
5. Input the office contact information, including the name, phone number, and fax number where the authorization can be sent.
6. Enter the patient’s details: full name, date of birth, and primary care provider's name along with their last visit date.
7. Complete the ‘Services Requested’ section by including the CPT code with a brief description and the corresponding ICD-10 code with its description.
8. Specify the surgery center or hospital name and indicate whether the service is for inpatient or outpatient care.
9. If applicable, provide additional information for obstetrical care requests, including the Last Menstrual Period (LMP) date and any ultrasounds or NSTs performed.
10. Use the section for additional notes to include any relevant information that may assist in processing the request.
11. After entering all required information, save your changes, then download, print, or share the completed form as necessary.

Complete your MemorialCare Referral Authorization Request Form online today!