Get Uchealth Referral/pre-authorization Form 2018-2025
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How to fill out the UCHealth Referral/Pre-Authorization Form online
Filling out the UCHealth Referral/Pre-Authorization Form online can be a straightforward process when you understand each component of the form. This guide provides step-by-step instructions to ensure you can complete the form accurately and efficiently.
Follow the steps to complete the form correctly.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering the patient's name, date of birth, and member ID in the designated fields. Ensure the information is accurate and matches the records.
- In the 'PCP/Referring Physician' section, provide the name of the referring physician. This should be printed clearly to avoid any miscommunication.
- Indicate the date of the request in the appropriate field. This date is essential for processing the referral in a timely manner.
- Enter the name of the referred provider and the referred facility. It's important to provide the correct details for both to facilitate proper routing.
- Describe the diagnosis accurately and enter the corresponding ICD10 code to ensure proper classification of the patient's condition.
- List the services requested and include the relevant CPT/HCPC codes. This information is crucial for the authorization process.
- For surgery requests, fill in the date of service and check if it is an inpatient or outpatient procedure as applicable.
- The physician should sign and date the form in the designated area, confirming the accuracy of the information provided.
- Complete the contact person’s details, including their name and telephone number, for any follow-up communication regarding the referral.
- Review all entered information for accuracy and completeness before finalizing.
- Once you have verified that everything is correct, you can save changes, download the completed form, print it out, or share it as necessary.
Complete your UCHealth Referral/Pre-Authorization Form online today.
Related links form
A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor.
Fill UCHealth Referral/Pre-Authorization Form
This outpatient clinic referral form is available for all UCHealth clinics including the following regions. The following information will be necessary in order to process this referral and obtain authorization for the visit. We've designed our digital tools to help you seamlessly submit and verify your prior authorizations and advance notifications in real time. Upon request for service, the following items MUST accompany patient referral: Medical Records: • All patient health history. My Health Connection (MHC) support. Phone number (available Monday-Friday, 9 a.m. My Health Connection (MHC) support. Phone number (available Monday-Friday, 9 a.m. In most cases, the referring provider must submit a Referral Consultation Request to the Alliance, via the Provider Portal, in order to authorize the referral. The CCS program requires prior authorization for services.
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