Humana Medicaid Family Referral Form PDF Details

The Humana Medicaid Family Referral form serves a critical role in the interface between patients, healthcare providers, and insurance coverages, especially within the military healthcare services ecosystem. It is designed to facilitate the referral process for patients needing authorization for various medical services that are considered necessary based on their health condition. This comprehensive form covers several essential sections including patient information, details about other health insurance, primary care manager (PCM) information, and specific referral information required for processing. It also caters to special circumstances like motor vehicle accidents or work-related cases, and it provides space for detailing other health insurance coverages a patient might have. Additionally, the form outlines the process for submitting referrals through online services when available, but also accommodates those without internet access by allowing for submission via fax. Importantly, the form is constructed with an understanding of medical necessity and TRICARE eligibility, underlining that filing this form does not guarantee payment but is a necessary step in seeking authorization for services. The form ensures a streamlined communication pathway between all parties involved, emphasizing the military health plan's nondiscriminatory policy, which guarantees services without bias towards beneficiary demographic or socio-economic factors. A signature section for the release of medical records indicates the patient's consent for information sharing, crucial for the coordination of care and services.

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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