Universal Referral Form Nevada PDF Details

Are you in need of a referral form for Nevada your business or organization? A universal referral form can be an invaluable asset to any organization that provides services within the state. It serves as a useful one-stop shop, not just for informational purposes but also helping streamline and expedite processes related to customer service, referrals, and sales. With this blog post, we’ll discuss what makes up a universal referral form in Nevada and why having one is essential for businesses operating in the state. We’ll touch on topics regarding its benefits, drawbacks, various templates available online as well as some tips for creating your own custom document if needed. So lets dive right into exploring everything you need to know about utilizing universal forms in the great state of Nevada!

QuestionAnswer
Form NameUniversal Referral Form Nevada
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesUniversal Referral Prior Auth form referal sheet of anc form

Form Preview Example

NEVADA UNIVERSAL

PRIOR AUTHORIZATION AND REFERRAL FORM

Health Plan of Nevada (HPN):

 

 

 

 

 

 

 

 

 

 

 

 

Primary Care Provider Name / Address / Phone & Fax #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nevada Exchange:

 

 

 

 

 

Tier I (HMO)

 

 

Tier II (PPO)

 

Tier III

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sierra Choice:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Senior Dimensions:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Smart Choice/Nevada Check Up:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sierra Health and Life:

 

 

Out of plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sierra Spectrum:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone: (LV) 702-242-7330 (outside LV) 800-288-2264

 

 

Requesting Provider Name:

Fax #: (LV) 702838-8297 (outside LV) 888-633-9301

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Request:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member Name & member number:

 

 

 

 

 

 

 

Requesting Provider’s Address & Phone #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Requesting Provider’s Fax #:

 

 

 

 

 

 

 

 

 

 

Members Address & Phone #:

 

 

 

 

 

 

 

Requesting Provider’s Tax ID #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HIPAA Provider Identification #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member’s DOB:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Person (Name, Phone & Fax # :)

 

 

 

 

 

 

 

 

 

 

Employer Group’s Name & Phone #:

 

 

 

 

 

 

 

Requesting Provider’s Signature or Stamped Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Insurance(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnosis (incl. ICD code):

 

 

 

 

 

 

 

Procedure/Treatment Request (incl. CPT code):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of Treatments Requested: ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inpatient / Outpatient:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Services Requested by Patient: YES NO

 

 

 

 

 

 

 

 

 

 

Service Provider / Address / Phone #:

 

 

 

 

 

 

 

Place of Service / Facility and Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Requested Procedure Date / Start Treatment Date:

 

 

 

 

 

 

 

 

Area for internal health plan use only

 

 

Authorization:

 

 

 

 

 

Date of Authorization:

Pended / Denied: (Reason):

CURRENT CLINICAL FINDINGS AND

MANAGEMENT

 

use the space – also see requirements below and attach to this form.

All procedures/treatment requested require

clinical information (may

Health Plan Contact name & phone #:

 

 

Yes

 

No

Authorization Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*All sections of this form must be completed.

Pertinent Attachments=Information to support the proposed diagnosis, treatment/procedure; i.e. current clinical findings (progress reports), results

of laboratory testing, imaging studies (x-rays, etc.) must be submitted to prevent processing delays.

**On adverse determinations a reconsideration / expedited appeal may be requested.

* All Sections of this form must be completed.

**On adverse determinations a reconsideration / expedited appeal may be requested.

This referral/authorization is not a guarantee of payment. Payment is contingent upon eligibility, benefits available at the time the service is rendered, contractual terms, limitations, exclusions, and coordination of benefits, and other terms & conditions set forth in the member’s Evidence of Coverage, Certificate of Coverage, or Self Insured Employer’s Plan Documents.

The information contained in this form, including attachments, is privileged and confidential & 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 the agent responsible to deliver 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.

Revised 2/24/16

S4590 (02/16)

Universal Referral Form Nevada isn’t the one you’re looking for?

Related Documents