Referral pre-authorization form: Fill out & sign online

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out referral pre-authorization form with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the referral pre-authorization form in the editor.
Begin by entering the patient's name, date of birth, and member ID in the designated fields. This information is crucial for identifying the patient.
Next, provide details about the referring physician by printing their name and including the date of request. This establishes who is initiating the referral.
Fill in the referred provider and facility names. Accurate information here ensures that services are directed appropriately.
Specify the diagnosis and include the corresponding ICD10 code. This helps in processing the pre-authorization efficiently.
List the services requested along with their CPT/HCPC codes. These codes are essential for billing and insurance purposes.
For surgery requests, indicate whether it is inpatient or outpatient and provide a date of service.
Finally, ensure that a physician signature is included along with their contact information for any follow-up required.

Start using our platform today to fill out your referral pre-authorization form online for free!

See more referral pre-authorization form versions

We've got more versions of the referral pre-authorization form form. Select the right referral pre-authorization form version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2018	4.1 Satisfied (55 Votes)
2014	4 Satisfied (38 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

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

Contact us

Is a pre-authorization a referral?

A referral is when your primary care manager or provider sends you to another provider for care that they dont provide. A pre-authorization is when your regional contractor approves your care before you go to your appointment.

Does a referral count as prior authorization?

Although the term referral is often used interchangeably with prior authorization, they are not the same thing. While a prior authorization requests coverage for a medication, service, or treatment, a referral requests coverage for a specialist visit or for specialized medical service.

Is prior authorization the same as a referral?

If your provider submits the request, they will send the required information to your health plan. You may need to fill out forms for your providers office. A prior authorization form will include information about you, your medical conditions, and your health care needs.