Empire Referral Form PDF Details

Are you looking for a referral form to help manage your empire business? Look no further than the Empire Referral Form. This form is designed to help you keep track of customer referrals and their corresponding information. Plus, it's easy to use and customizable to fit your needs.

If you wish to first understand how much time you need to complete the empire referral form and what number of pages it has, here is some detailed information that will be of use.

QuestionAnswer
Form NameEmpire Referral Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesempire referral form, empire blue cross referral form, blue cross blue shield referral form, empire bcbs referral form

Form Preview Example

Managed Care Referral Form

PO BOX 1407, Church Street Station

New York, New York 10008- 1407

Fax no. 1-800-522-5793

www.empireblue.com

Reference no.

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)

}

Empire Baby Care

}

Surgery not performed in doctor’s office

Health Plans that require a referral to an Empire participating provider are:

}HMO

}Child Health Plus

}Healthy NY

}Direct Pay HMO

}Direct Pay HMO/POS

* Required field. If any required field is missing, the referral will not be accepted.

Section 1. PATIENT INFORMATION

*Patient ID no.

---

*Patient last name

Policyholder last name

 

 

 

 

 

 

 

 

*Date of birth (MM/DD/YYYY)

*Patient first name

 

 

 

 

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policyholder last name

 

 

 

 

 

 

 

MI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 2. REFERRING PHYSICIAN INFORMATION

*Provider last name

*Provider first name

MI

Service address

*Empire provider ID or NPI

 

Phone no.

Section 3. REFERRING TO INFORMATION

 

 

 

 

*Specialist last name

 

*Specialist first name

 

 

 

 

MI

Service address

*Empire provider ID or NPI

Phone no.

Section 4. AUTHORIZATION INFORMATION

Referrals are valid for 90 daysfrom 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

*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.

 

12895NYPEN 3/10

The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

1

 

 

How to Edit Empire Referral Form Online for Free

The blue cross blue shield referral form completing process is quick. Our software lets you use any PDF document.

Step 1: Hit the button "Get form here" to open it.

Step 2: Now you can edit the blue cross blue shield referral form. You can use the multifunctional toolbar to add, remove, and transform the text of the document.

All of the following areas will make up the PDF document:

filling out bcbs referral form part 1

Fill in the Provider last name, Service address, Provider first name, Empire provider ID or NPI, Phone no, Section REFERRING TO INFORMATION, Specialist last name, Service address, Specialist first name, Empire provider ID or NPI, Phone no, Section AUTHORIZATION INFORMATION, Referrals are valid for days from, No of visits, and Service start date MMDDYYYY areas with any details that can be demanded by the program.

step 2 to completing bcbs referral form

You can be demanded particular necessary details to fill in the Referral reasonremarkslimitations, Signature of referring physician, Date MMDDYYYY, NYPEN, and Services provided by Empire field.

Entering details in bcbs referral form stage 3

Step 3: As you press the Done button, your ready document can be easily exported to any kind of your gadgets or to email indicated by you.

Step 4: Generate copies of the template. This would protect you from potential future troubles. We do not watch or disclose your data, so be certain it's going to be protected.

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