Teleform Internet Form Image REFERRAL AUTHORIZATION FORM
PCP TO SPECIALIST ONLY
REFERRAL DATE
PATIENT INFORMATION
PATIENT LAST NAME PATIENT FIRST NAME
PATIENT ID#
PATIENT DOB
SELECT PLAN FROM BELOW
PROMINA HEALTH PLAN HUMANA PRINCIPAL ONE HEALTH PLAN OTHER PLEASE SPECIFY
CIGNA UNITED BLUE CHOICE
PRIMARY CARE PHYSICIAN INFORMATION
PCP FIRST NAME PCP LAST NAME
PCP PHONE NUMBER PCP ID#
PCP FAX NUMBER
SPECIALTY CARE PHYSICIAN INFORMATION
SPECIALIST FIRST NAME SPECIALIST LAST NAME
SPECIALIST PHONE NUMBER REFERRAL APPOINTMENT DATE (If known)
SPECIALIST FAX NUMBER SPECIALIST ID#
ICD-9 CODE PRIMARY DIAGNOSIS
PRIMARY DIAGNOSIS
ICD-9 CODE SECONDARY DIAGNOSIS
OTHER DIAGNOSIS
This referral is valid for 90 days:
1 visit - Consult only:
2 visits - Consult and 1 follow up visit:
3 visits - Consult and 2 follow up visits:
Unless otherwise noted, this referral is valid for a maximum of 1visit within 90 days.
This form is not valid for referrals to non-participating providers. Please refer to the Plan Provider Directory to identify participating providers. This referral is not a guarantee of payment. Please verify eligibility of the patient prior to rendering any services. Eligibility for benefits may be subject to plan limitations such as pre-existing conditions or non-covered services. To order more referral forms, contact PROMINA at 770-956-6970. ONE FORM PER REFERRAL.
Request for additional visits or referrals must be approved by PCP.
Copyright 1999 Promina Health Systems


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