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Click ‘Get Form’ to open the Blue Cross Blue Shield referral form in the editor.
Begin by filling out the Primary Care Physician Information section. Enter the physician's name, NPI, office contact details, and address. Ensure all fields are completed accurately for smooth processing.
Next, move to the Patient Information section. Input the patient's first and last name, date of birth, contract holder’s name (if applicable), group number, relationship to patient, contract number, and sex.
In the Diagnosis Information section, provide relevant details about the patient's condition that necessitates a referral.
Complete the Referral Information section by specifying the specialist or hospital name, UPIN, referral dates, and number of visits if applicable. Indicate whether it is an ER referral.
Finally, include any comments regarding why the referral was not completed within 72 hours and ensure you sign and date the form before submission.

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