TELEform Internet Solution

REFERRAL AUTHORIZATION FORM
PCP TO SPECIALIST ONLY

REFERRAL DATE

PATIENT INFORMATION

PATIENT LAST NAME	PATIENT FIRST NAME

PATIENT ID#

PATIENT DOB

SELECT PLAN FROM BELOW
	PROMINA HEALTH PLAN	HUMANA		PRINCIPAL	ONE HEALTH PLAN		OTHER	PLEASE SPECIFY
	CIGNA		UNITED			BLUE CHOICE

PRIMARY CARE PHYSICIAN INFORMATION

PCP FIRST NAME	PCP LAST NAME

PCP PHONE NUMBER	PCP ID#

PCP FAX NUMBER

SPECIALTY CARE PHYSICIAN INFORMATION

SPECIALIST FIRST NAME	SPECIALIST LAST NAME

SPECIALIST PHONE NUMBER	REFERRAL APPOINTMENT DATE (If known)

SPECIALIST FAX NUMBER	SPECIALIST ID#

ICD-9 CODE PRIMARY DIAGNOSIS
	PRIMARY DIAGNOSIS

ICD-9 CODE SECONDARY DIAGNOSIS
	OTHER DIAGNOSIS

This referral is valid for 90 days:
	1 visit - Consult only:
	2 visits - Consult and 1 follow up visit:
	3 visits - Consult and 2 follow up visits:

Unless otherwise noted, this referral is valid for a maximum of 1visit within 90 days.

This form is not valid for referrals to non-participating providers. Please refer to the Plan Provider Directory to identify participating providers. This referral is not a guarantee of payment. Please verify eligibility of the patient prior to rendering any services. Eligibility for benefits may be subject to plan limitations such as pre-existing conditions or non-covered services. To order more referral forms, contact PROMINA at 770-956-6970. ONE FORM PER REFERRAL.
Request for additional visits or referrals must be approved by PCP.