Referral Authorization Form – Fill Out and Use This PDF

For large medical practices and corporations, having a Referral Authorization Form is essential for staying efficient and organized. Without such a form in place, there can be costly consequences to a company's bottom-line from administrative mistakes or HIPAA violations. This form acts as an official document that approved individuals use to refer patients outside of their current practice or hospital. Not only are the originator’s name and information included on the form, but the groups receiving these referrals are also listed in great detail too. Ultimately, this authorization implies that physicians need to have signatures before they can officially refer patients to available physical therapy consultations, radiology studies, and other hospital departments. In addition, it helps to collect private patient information at each staging point reliability by authorized personnel.

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Referral Authorization Form PDF Details

Having a clear and transparent authorization process is key to exercising proper patient-doctor communication. Being aware of the forms necessary for each health care provider can help ensure that information is properly obtained and shared by healthcare professionals in order to provide patients with the highest quality of care. A Referral Authorization Form serves as an important part of this process, providing timely approval on any referral requests and giving physicians all relevant details while protecting their patients’ privacy along the way. In this blog post, we'll be looking at exactly what makes up a referral authorization form so you can feel confident when it comes time to filling out your own!

Question	Answer
Form Name	Referral Authorization Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	outside referral form parkland hospital, parklabd referral form, parkland referrals, parkland outside referral form

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Texas Referral/Authorization Form

Please fill out form completely in blue or black ink. Refer to instruction sheet.

This referral does not guarantee payment. Please contact health plan to verify member eligibility and covered benefits.

CHIP EPO HMO PCCM POS PPO W/C OTHER ________

HEALTH PLAN NAME: ________________________ DATE ____/____/____

Health Plan Fax# (____)_____________

PATIENT INFO.

Patient name ______________________________________________________________

LAST	FIRST	MI.
DOB ______/________/______	Sex M F Phone # (____)____________________

Member ID #____________________ Member Social Sec. # ______-_________-________

OPTIONAL

REFERRED BY

Physician name __________________________________________________________

LAST	FIRST			M.I.
Provider # _________________________________		PCP	SCP	HOSPITAL
Fax # (______)____________________

Contact name __________________________ Phone # (_____)_________________

REFERRED TO

Provider name ____________________________________________________________

	LAST		FIRST		M.I.
Specialty type ___________________________				Provider/Facility #	_________________
Fax # (_____)____________________ Phone # (_____)_______________________
Provider City ____________________________, Texas
REFERRED TO LOCATION
Office	Outpatient facility***		Inpatient	23 Hour observation
	***Note for outpatient facility, List CPT4 at right
ER/Post Stabilization		Other	Date of service _______/________/______

Facility name _____________________________________________________________

Facility # * _____________________________* Required for ER/UCC, Therapy and Outpatient services.

COMMENTS/CLINICAL HISTORY __________________________________________

________________________________________________________________________

Clinical information attached:	Y / N	# of pages _____
PHYSICIAN SIGNATURE-	_________________________________________________

The information contained in this form is privileged and confidential and is only for the use of the individual or entities named on this form. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited If this communication has been received in error, the reader shall notify sender immediately and shall destroy all information received.

HEALTH SERVICES RESPONSE

Approved as requested	Authorization # ___________________
	Expiration date ______/______/______
	Days authorized _____

ROUTINE URGENT

EMERGENCY

OUT OF NETWORK

REVISED REFERRAL

NOTIFICATION ONLY

Requested

Start date ____/_______/_______

Requested

End date _____/_______/_______

ICD-9/DSM4/Diagnosis___________

______________________________

Scope of referral

Consultation

Diagnostic Testing

Follow-up

Number of visits _____

SPECIFIC SERVICES REQUESTED**

**Refer to specific plan instructions.

Certification/authorization guidelines must be followed.

Behavioral Health Dialysis DME/Prosthesis/Supplies

Case Mgmt. ___________________

_____________________________

Health Educ. __________________

_____________________________

Home Care

Injections and IV Therapy Maternity Services:

EDC ________________________

Vaginal C-Section

Lab/Pathology

Radiology/ Imaging

Therapy: Indicate # of visits ________

Physical	Cardiac Rehab
Speech	Occupational

Visits/Week _____

Surgery ____________(CPT4 code)

Assistant Surgeon

TO AUTHORIZE ONLY (OR OTHER) SPECIFIC SERVICES, INCLUDE CPT4 /MEDICAID LOCAL OR HCPCS CODES HERE.

_____________ _____________

Medical Director Review Pending Info. No referral needed Denied Approved with modification

NOTES __________________________________________Signature _____________________________Date: ___/___/_____

Referral Authorization Form – Fill Out and Use This PDF

Referral Authorization Form PDF Details

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