Empire Referral Form – Fill Out and Use This PDF

The Empire Referral Form is a crucial document designed for individuals enrolled in specific health plans, such as HMO, Child Health Plus, Healthy NY, Direct Pay HMO, and Direct Pay HMO/POS, requiring a referral to an Empire participating provider. It outlines the necessary steps and information needed to facilitate managed care referral, including patient and physician information, details of the specialist to which the patient is being referred, and authorization information to ensure the referral is valid and adheres to the limitations and exclusions of the contract. For those looking to navigate their healthcare needs effectively, filling out the Empire Referral Form is an essential step; click the button below to begin.

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Empire Referral Form PDF Details

Navigating the healthcare system can often feel like solving a complex puzzle, especially when it comes to understanding how referrals work within managed care plans. For those covered under certain health plans like HMOs or Child Health Plus in New York, the Empire Referral form is a key piece of this puzzle. Located conveniently online and at select locations, it serves as a critical bridge between patients, their primary care physicians (PCPs), and specialists. With specific sections dedicated to patient information, referring physician details, and the specialist to whom the referral is made, this form is meticulously designed to ensure smooth transitions within the healthcare framework. It highlights the necessity of referrals for a range of services, from inpatient admissions to surgeries not performed in a doctor's office, and clarifies the exceptions that require direct approval from Empire Medical Management. Essential fields must be filled to validate the referral, emphasizing the form's role in managing patient care while adhering to the contractual limitations and exclusions. The form itself symbolizes a commitment to organized, efficient healthcare delivery by facilitating authorized services for a set duration, generally valid for 90 days unless otherwise stated. In essence, understanding and properly utilizing the Empire Referral form can significantly enhance one’s healthcare experience, ensuring access to necessary specialist care while remaining within the bounds of one's health plan.

Question	Answer
Form Name	Empire Referral Form
Form Length	1 page
Fillable?	Yes
Fillable fields	30
Avg. time to fill out	15 sec
Other names	empire referral form, empire blue cross referral form, blue cross blue shield referral form, empire bcbs referral form

How to Fill Out Managed Care Referral Form

Managed Care Referral Form at a glance

What it is: The Managed Care Referral Form is for the health plans that require a referral.

Where and when to file: The form lists PO BOX 1407, Church Street Station New York, New York 10008-1407 and Fax no. 1-800-522-5793.

A filled-in Managed Care Referral Form example: a physician refers a patient

Managed Care Referral Form example filled out, example: a physician refers a patient — A physician refers a patient to a specialist on the referral form. The referral covers 6 visits, with a service start date of March 2, 2026. The picture shows the whole form, and none of its entries is real. The service end date, May 30, 2026, falls within 90 days of the service start date. The physician signs on February 27, 2026, before the service starts.

How to fill out Managed Care Referral Form, box by box

Reference no.

Enter the Reference no.

Section 1. Patient Information

Health Plans that require a referral to an Anthem participating provider are HMO, POS, Direct POS, Pathway Enhanced, Gated, Pathway X Enhanced, Gated, Blue Access, EPO Gated and Blue Access, HMO Gated.

In Section 1, enter the *Patient ID no., *Date of birth (MM/DD/YYYY), *Patient last name, *Patient first name and MI, then the *Policyholder last name, *Policyholder first name and MI.

Section 2. REFERRING PHYSICIAN INFORMATION

In Section 2, enter the *Provider last name, *Provider first name, MI, Service Address, *Anthem Provider ID or NPI and Phone no..

Section 3. REFERRING TO INFORMATION

Under Secton 3, fill in the *Specialist last name and *Specialist first name with MI, then the Service Address, *Anthem provider ID or NPI and Phone no..

Section 4. AUTHORIZATION INFORMATION

Referrals are valid for 90 days from the service start date unless otherwise specified.

Authorized Services are subject to Limitations/Exclusions of Contract.

Enter the No. of visits, the *Service Start Date (MM/DD/YYYY) and the *Service End Date (MM/DD/YYYY).

Write the Referral reason/remarks/limitations.

Signature of referring physician

After the No. of visits, *Service Start Date and *Service End Date, sign on the *Signature of referring physician line and enter the *Date (MM/DD/YYYY).

If your situation is different

The service is one a referral is not valid for

Referrals are not valid for these services, so contact Anthem Medical Management at 1-800-441-2411 for approval: Non-participating Provider's, Emergency/Maternity Admissions, Anthem Baby Care, Inpatient Admission to Hospital/Facilities, Home Care, Hospice, Private Duty Nursing (at home), Surgery not performed in doctor's office and Urgent Care Centers.

Common questions about Managed Care Referral Form

Where do I file it?

The form lists PO BOX 1407, Church Street Station New York, New York 10008-1407 and Fax no. 1-800-522-5793.

Sources

[1] Managed Care Referral Form (01/24), Anthem Blue Cross and Blue Shield (the Official source link on this page).