Humana Medicaid Family Referral Form PDF Details

When it comes to signing up for Humana Medicaid, the process can be overwhelming – but it doesn’t have to be. At Humana, we understand that ensuring your family has access to healthcare is of utmost importance, so we make sure our members get the coverage they need with easy access to forms and resources. In this blog post we’ll walk you through understanding and filling out the Humana Medicaid Family Referral Form. We'll address any questions you might have about getting started on this crucial step in establishing yourself as a member of Humana's network and gaining peace of mind that your family will remain safe and healthy covered by insurance you can trust. So let's get started!

QuestionAnswer
Form NameHumana Medicaid Family Referral Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshumana patient referral authorization form, humana referral form, humana pcp referral form, humana authorization forms printable

Form Preview Example

MilitaryHealthcareServices

P ATI EN T REFERRAL AUTHORI ZATI ON FORM

 

TRICARE referrals should be submitted through www.humana-military.com, select 'Online Provider Services'

If you do not have internet connection in your office - you may print, complete, then fax to: 1-877-548-1547.

Referral is based on medical necessity, subject to TRICARE eligibility, and is not a guarantee of payment.

AUTHORIZATION NUMBER:________________

SECTION I: PATIENT INFORMATION:

Last Name:________________________ First Name:______________________ MI:____

DOB:_____________

Address:________________________________________________ Phone: (home)_________

(work)______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sponsor's Name:__________________________________________ Sponsor's

 

 

 

 

SSN_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION II: OTHER HEALTH INSURANCE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Motor Vehicle Accident: ¨ Yes ¨ No

 

 

 

Work Related Case: ¨ Yes

¨ No

Other Health Insurance: Policy Holder ____________________

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Carrier Name ______________

___ Carrier Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Effective Date:_______________ __ Policy ID #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Medicare: HIC Number ___________________ Part A Effective Date: ________ Part B Effective Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III: PCM INFORMATION

REFERRAL TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PCM Name:

 

 

Specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Phone:

 

 

Provider Name:

 

 

 

 

 

Office Fax:

 

 

Address:

 

 

 

 

 

Contact Person:

 

Office Phone:

 

 

 

 

 

Office Fax:

 

 

Contact Person:__________________ Fax:

 

 

PCM Signature _____________________________________________________________ Date:

SECTION IV: REFERRAL INFORMATION:

¨ Consult Only

 

Appointment or Beginning Date:

 

¨ Consult and Treat

No. Expected Visits:______________

Diagnosis:

 

Requested Time Frame: From __________ To ___________

ICD 9 Diagnosis Code:

 

¨ Surgical Intervention

 

CPT Code:

 

Requested Services:_________________________________

Other:

 

Clinical Information/Physician Assessment: (include history, treatment plan, lab results, or medications to support medical necessity)

RELEASE OF MEDICAL RECORDS

'I authorize the release of medical information resulting from this referral and ancillary services to the providers shown on this form."

Beneficiary Signature ___________________________________

Date___________________

The TRICARE Program is a nondiscriminatory program for TRICARE eligibles offered without regard to beneficiary age, race, religion, gender, rank, sponsor status, family size or personal income. TRICARE is the Military Health Plan administered in the South Region by Humana Military Healthcare Services.

PROPRIETARY TO HMHS, NOT TO BE DISCLOSED

3/04

TP34-2568

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