Ob gyn referral 2026

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4.8 out of 5

156 votes

The document is a referral form for Gateway Health Plan, specifically for OB/GYN services. It outlines the necessary provider and patient information required for issuing referrals, emphasizes that each referral requires a new form, and specifies that referrals are valid for 90 days. It also notes that members must be referred to specialists through their primary care practitioner, with exceptions for perinatologists, and highlights the importance of using designated laboratories for lab testing.

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Click ‘Get Form’ to open the ob gyn referral in the editor.
Begin by filling out the PROVIDER INFORMATION section. Enter the OB/GYN Provider Name and Provider Number, ensuring accuracy for claims payment.
Next, move to the PATIENT INFORMATION section. Fill in the Patient Name, Gateway Member ID#, Diagnosis/Complaint, and Provider Phone #. This information is crucial for processing referrals.
In the FACILITY INFORMATION section, specify the Facility Name and Facility Provider ID#. Ensure that all details are correct as this will affect service validation.
Review the Referred Services options and check any applicable boxes. Specify lab testing details if necessary.
Finally, sign and date the form in the OB/GYN Signature and Referral Date fields. Remember, an unsigned form is invalid.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (156 Votes)
2013	4.2 Satisfied (39 Votes)

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