Member Outreach Form - Gateway Health Plan 2026

1. Click ‘Get Form’ to open the Member Outreach Form in the editor.
2. Begin by filling in the required fields at the top of the form, including Member Name, Age, Gateway Health ID #, and Date of Birth. Ensure all information is accurate as it is essential for processing.
3. Next, provide details about the Parent/Guardian, including their name, relationship to the member, and contact phone number with area code.
4. Fill in your Primary Care Provider (PCP) information: PCP Name, Provider ID#, Contact Person, and their Phone Number.
5. Indicate the date sent to Gateway Health Plan and specify if the member is being referred for any services. Check all applicable boxes related to EPSDT screenings or immunizations.
6. In the comments section, add any additional information that may assist in processing the referral effectively.
7. Once completed, save your changes and choose to either mail or fax the form as indicated at the bottom of the document.

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