Formulario De Remisi n De Educaci n Para La Salud 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Enter the member's last name, first name, middle initial, and date of birth. Ensure accuracy as this information is crucial for identification.
3. Continue with the MEMBER ID NUMBER, ADDRESS, CITY, STATE, and ZIP fields. Double-check these details to avoid any delays in processing.
4. In the REFERRAL INFORMATION section, provide the name and contact details of both the treating physician and primary care provider (PCP). This ensures proper communication regarding the referral.
5. Select the REASON(S) FOR REFERRAL by checking all applicable boxes. This helps in directing the member to appropriate health education resources.
6. Finally, complete the CLINICAL INFORMATION section with the name and title of the person completing the form along with their contact number and date.

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