Texas referral authorization form pdf 2026

1. Click ‘Get Form’ to open the Texas Referral Authorization Form in our platform's editor.
2. Begin by filling out the health plan information at the top, including the health plan name and fax number. Ensure you select the appropriate coverage type.
3. In the 'Patient Info' section, enter the patient's full name, date of birth, sex, phone number, member ID, and social security number if applicable.
4. Complete the 'Referred By' section with the referring physician's details, including their name and provider number. Indicate whether this is a routine or urgent referral.
5. Specify the requested start and end dates for the referral along with any relevant diagnosis codes in the ICD-9/DSM4 section.
6. Fill in details about the services requested and ensure to include specific provider information in the 'REFERRED TO' section.
7. Finally, review all entries for accuracy before signing at the bottom of the form. Save your changes and export or share as needed using our platform’s features.

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