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PAD Referral Form v2 - Passport

PAD Referral Form v2 - Passport 2026

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The document is a referral form for Passport Advantage Plan members, detailing required fields for member and provider information, guidelines for referrals from primary care providers (PCPs) to specialists or urgent care, and stipulations regarding the processing of referrals. It emphasizes that services rendered without a referral will not be covered and outlines the conditions under which referrals can be issued.

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Click ‘Get Form’ to open the PAD Referral Form v2 - Passport in our editor.
Begin by filling in the required fields marked with an asterisk. Start with the *Member ID#, *PCP/PCP Group Name, and the member's full name including *Last Name and *First Name.
Enter the *Member Date of Birth and the *PCP/PCP Group ID#. Ensure all information is accurate to avoid processing delays.
In the section labeled 'This member is being referred to', provide details about the specialist or facility, including *Referred to, *Provider ID, and *Specialty type. Fill in the address fields: *Street Address, *City, and *Zip.
Complete the diagnosis code(s) field as required. Then, check one of the options for referral type and specify the number of visits allowed.
Finally, sign and date the form at the bottom before sending a copy via fax or email as instructed.

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