Get Unt0001-1e 2013

The UNT0001-1E is a uniform consultation referral form designed to facilitate the referral process between primary care providers and specialists. This guide provides clear, step-by-step instructions on how to fill out this form online, ensuring that users can complete the process efficiently and accurately.

Follow the steps to complete the UNT0001-1E form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by filling out the patient information section, providing the patient's full name, date of birth, phone number, ID number, site number, referral number, and date of referral.
3. In the carrier information section, circle the appropriate carrier name from the options provided: CareFirst BlueChoice or CareFirst BlueCross BlueShield.
4. Proceed to the primary or requesting provider section, where you will need to enter the provider's full name, specialty, institution or group name, and provider ID. If necessary, provide a second provider ID.
5. Fill in the consultant/facility provider details by entering the specialist's full name, specialty, institution or group name, and provider ID, including a second provider ID if applicable.
6. For the referral information section, specify the reason for the referral along with a brief history, any diagnosis, and test results.
7. In the services desired section, indicate the initial consultation preference, desired diagnostic tests or procedures, specific treatments, and the number of visits. If left blank, three visits will be assumed.
8. Select the place of service by placing an X in the appropriate checkbox for the office or other listed locations. Provide the referral's expiration date and complete the authorizing signature section if required.
9. Once all sections are completed, review the form to ensure accuracy. Users can then save the changes, download, print, or share the form as needed.

Complete your UNT0001-1E document online today to streamline your referral process.