Follow the steps to successfully complete the referral request online.

1. Click ‘Get Form’ button to access the form and open it for editing.
2. Fill in the member's name and the group or IPA name in the designated fields. Ensure accuracy as this information is essential for processing the referral.
3. Enter the date and the date of birth of the member. This helps verify their identity.
4. Input the health plan and insurance ID number. If applicable, include the MRN for Sutter Medical Group or Sutter West Medical Group.
5. If prior authorization is needed, select ‘STAT,’ ‘URGENT,’ or ‘ROUTINE’ based on the urgency of the case.
6. Provide the clinician referred to, along with the number of visits requested and the effective and expiration dates of the referral.
7. Detail the specialty required and include the address, phone number, and fax number of the clinician.
8. Schedule the appointment by specifying the date, time, and type of appointment (for example, consult only or follow-up visits).
9. Enter a brief medical history of the member as this is required for further processing. Include details of work-up to date, diagnosis, and necessary codes (CPT and ICD-9).
10. Attach any relevant documents, such as most recent history and physical, office notes, imaging results, or lab/pathology reports that may support the referral.
11. Complete the referring clinician's information, including contact details, and include the NPI number.
12. Finally, review all information for accuracy. Users can then save the changes, download, print, or share the completed form as needed.

Complete your requests online to streamline the referral process.