Get Unt0001-1e 2018-2025

The UNT0001-1E form is a vital document for facilitating referrals within health care plans. This guide will assist you in successfully completing the form online, ensuring that all necessary information is accurately provided.

Follow the steps to fill out the UNT0001-1E online with ease.

1. Click the ‘Get Form’ button to access the UNT0001-1E form and open it for editing.
2. Complete section 1, titled 'Patient Information.' Provide the patient's name (last, first, middle initial), date of birth, phone number, ID number, and referral number.
3. In section 2, 'Carrier Information,' select the appropriate carrier name by checking one of the provided options.
4. Move to section 3, 'Primary or Requesting Provider.' Fill in the name, specialty, institution or group name, and provider ID. If necessary, include another provider ID.
5. Section 4 pertains to the 'Consultant/Facility Provider.' Repeat the steps for the primary provider but for the consulting specialist's information.
6. In section 5, 'Referral Information,' state the reason for the referral and provide a brief history, diagnosis, and relevant test results.
7. Consider section 6, 'Service Desired.' Indicate the number of visits required. If this field is left blank, a default of three visits will be assumed.
8. For section 7, 'Place of Service,' select the appropriate location by marking the office checkbox. Fill in the 'Referral is Valid Until' date and any required signatures.
9. After completing all sections, ensure all information is accurate. You can then save changes, download, print, or share the form accordingly.

Start completing your UNT0001-1E form online today for a smooth referral experience.