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?Yes
Fillable fields28
Avg. time to fill out5 min 51 sec
Other namesbcbs hmo referral form, empire bcbs referral form, managed care referral form, blue cross blue shield 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

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Step 1: The initial step is to choose the orange "Get Form Now" button.

Step 2: Once you've got entered the editing page managed care referral form bcbs, you should be able to see all the actions available for your document inside the top menu.

You'll need to provide the following details so you can fill in the document:

empire blue cross referral form empty fields to complete

Enter the required details in the area *Patient ID no, *Patient last name, *Date of birth (MM/DD/YYYY), *Patient first name, Policyholder last name, Policyholder last name, Section 2, *Provider last name, Service address, *Provider first name, *Empire provider ID or NPI, Phone no, Section 3, *Specialist last name, and *Specialist first name.

empire blue cross referral form *Patient ID no, *Patient last name, *Date of birth (MM/DD/YYYY), *Patient first name, Policyholder last name, Policyholder last name, Section 2, *Provider last name, Service address, *Provider first name, *Empire provider ID or NPI, Phone no, Section 3, *Specialist last name, and *Specialist first name blanks to fill out

Mention the important information in Service address, *Empire provider ID or NPI, Phone no, Section 4, Referrals are valid for 90 days, Referral reason/remarks/limitations, *Service start date (MM/DD/YYYY), *Service end date (MM/DD/YYYY), *Signature of referring physician, *Date (MM/DD/YYYY), 12895NYPEN 3/10, The Blue Cross and Blue Shield, and Services provided by Empire section.

Completing empire blue cross referral form step 3

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