Get Uchealth Referral/pre-authorization Form 2018-2025

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.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. 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.
3. In the 'PCP/Referring Physician' section, provide the name of the referring physician. This should be printed clearly to avoid any miscommunication.
4. Indicate the date of the request in the appropriate field. This date is essential for processing the referral in a timely manner.
5. 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.
6. Describe the diagnosis accurately and enter the corresponding ICD10 code to ensure proper classification of the patient's condition.
7. List the services requested and include the relevant CPT/HCPC codes. This information is crucial for the authorization process.
8. For surgery requests, fill in the date of service and check if it is an inpatient or outpatient procedure as applicable.
9. The physician should sign and date the form in the designated area, confirming the accuracy of the information provided.
10. Complete the contact person’s details, including their name and telephone number, for any follow-up communication regarding the referral.
11. Review all entered information for accuracy and completeness before finalizing.
12. 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.