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Gold coast direct referral form

Gold coast direct referral form 2025

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4.9 out of 5

45 votes

The document is a Direct Referral Authorization Form used for referring patients to specialists. It outlines the methods for making referrals, including downloading the form from the GCHP website, electronic requests, verbal requests via a call center, and written requests by mail or fax. It includes sections for PCP and member information, referral specialist details, authorization limitations, and effective dates. The form also specifies that for out-of-network referrals, a Preauthorization Treatment Request Form is required.

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Click ‘Get Form’ to open the gold coast direct referral form in the editor.
Begin by filling out the PCP INFORMATION section. Enter the PCP Group Name, Physician Name, Office Address, City, NPI #, State, Zip Code, and Office Phone.
Next, move to the MEMBER INFORMATION section. Provide details such as Member Name, Date of Birth, Primary Address, City, Primary Phone, Confirmed/Suspected Diagnosis, Member ID #, Age, State, Zip Code, Secondary Phone, and Duration of Symptoms.
In the REFERRAL SPECIALIST INFORMATION section, input the Group Name and Physician Name (if applicable), along with their Address, City, State, NPI #, Zip Code, and Office Phone.
Specify the DESCRIPTION OF AUTHORIZATION LIMITATION by selecting either 'Consultation only' or 'Consultation and Treat'. Remember that if prior authorization is needed for treatment indicated, a Preauthorization Request Form must be submitted.
Finally, complete the AUTHORIZATION EFFECTIVE DATES by entering the start and end dates of authorization. Don’t forget to include your PCP Signature and Date issued.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (30 Votes)
2011	4.9 Satisfied (45 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What insurance provider is Medi-Cal?

Medi-Cal is Californias Medicaid program, designed to help low-income individuals and families gain access to necessary medical and health care providers and services. The California Department of Health Care Services (DHCS) and the Centers for Medicare and Medicaid Services (CMS) oversee the program.

What is another name for Medi-Cal insurance?

Medi-Cal is Medicaid for California. It offers free or low-cost health coverage to people who qualify.

What is the fax number for Gold Coast University Hospital referral?

Please continue to submit referrals using secure electronic transmission (e.g. Medical Objects) where possible. If you currently fax referrals to Gold Coast Health, please note there is now only one fax number for all referrals (07) 5687 4497.

What kind of insurance is Gold Coast?

Gold Coast Gold Coast Health Plan (GCHP) is one of Californias premier models of managed care: The County Organized Health System (COHS). The COHS model delivers care to the states most vulnerable residents that is: High quality.

What counties does the Gold Coast Health Plan cover?

The Ventura County Board of Supervisors created GCHP in 2011 to serve the county. In that time, GCHP has: Developed programs that are uniquely tailored to the needs of Ventura County members.

Is Gold Coast Health Plan the same as Medi-Cal?

GCHP is your health plan in Ventura County after you qualify for Medi-Cal. You will be automatically enrolled in GCHP one to two months after you are eligible. GCHP will send you a new member packet. GCHP covers most Medi-Cal services.

Gold coast direct referral form 2025

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