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Get Empire Blue Cross Blue Shield 12895NYPENZ 2010-2021

Managed Care Referral Form PO BOX 1407 Church Street Station New York New York 10008- 1407 Fax no. 1-800-522-5793 Reference no. www. empireblue. com N PCP s Tracking no. Optional/not required Referrals are not valid for the following services please contact Empire Medical Management at 1-800-441-2411 for approval of these services Non-participating Provider s Inpatient Admission to Hospital/Facilities Emergency/Maternity Admissions Home Care Hospice Private Duty Nursing at home Surgery not performed in doctor s office Empire Baby Care Health Plans that require a referral to an Empire participating provider are HMO Child Health Plus Healthy NY Direct Pay HMO Required field. Managed Care Referral Form PO BOX 1407 Church Street Station New York New York 10008- 1407 Fax no. 1-800-522-5793 Reference no. www. empireblue. com N PCP s Tracking no. Optional/not required Referrals are not valid for the following services please contact Empire Medical Management at 1-800-441-2411 for approval of these services Non-participating Provider s Inpatient Admission to Hospital/Facilities Emergency/Maternity Admissions Home Care Hospice Private Duty Nursing at home Surgery not performed in doctor s office Empire Baby Care Health Plans that require a referral to an Empire participating provider are HMO Child Health Plus Healthy NY Direct Pay HMO Required field. If any required field is missing the referral will not be accepted* Section 1. PATIENT INFORMATION Patient ID no. Date of birth MM/DD/YYYY --- Patient last name Patient first name MI Policyholder last name Provider first name Section 2. REFERRING PHYSICIAN INFORMATION Provider last name Service address Empire provider ID or NPI Phone no. Specialist last name Specialist first name Section 4. AUTHORIZATION INFORMATION Referrals are valid for 90 days from the service start date unless otherwise specified* Please remember Authorized Services are subject to Limitations/Exclusions of Contract. No* of visits Service start date MM/DD/YYYY Service end date MM/DD/YYYY Referral reason/remarks/limitations Signature of referring physician 12895NYPENZ 3/10 Date MM/DD/YYYY Services provided by Empire HealthChoice HMO Inc* and/or Empire HealthChoice Assurance Inc* licensees of the Blue Cross and Blue Shield Association an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association*. www. empireblue. com N PCP s Tracking no. Optional/not required Referrals are not valid for the following services please contact Empire Medical Management at 1-800-441-2411 for approval of these services Non-participating Provider s Inpatient Admission to Hospital/Facilities Emergency/Maternity Admissions Home Care Hospice Private Duty Nursing at home Surgery not performed in doctor s office Empire Baby Care Health Plans that require a referral to an Empire participating provider are HMO Child Health Plus Healthy NY Direct Pay HMO Required field. If any required field is missing the referral will not be accepted* Section 1. PATIENT INFORMATION Patient ID no. .

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