Blue Cross Blue Shield of Michigan - TRUST PREFERRED PROVIDER ORGANIZATION (PPO) and POINT OF SERVICE (POS) PROGRAM REFERRAL FORM. TRUST PREFERRED PROVIDER ORGANIZATION (PPO) and POINT OF SERVICE (POS) PROGRAM REFERRAL FORM 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the subscriber's name, contract number, and member's details including last name, first name, and date of birth in the designated fields.
3. Fill in the referral details such as the non-PPO/POS physician, hospital, or laboratory name and address. Ensure you include their telephone number for contact purposes.
4. Provide information about the referring PPO/POS physician or hospital including their name, address, and license number.
5. Specify the reason for referral along with anticipated start date, length of treatment, and number of visits required.
6. Complete the section for referred physician/hospital/laboratory by indicating location and specific services requested. Don't forget to include ICD-9 diagnosis codes.
7. Ensure all required signatures are obtained from the patient or authorized person, non-PPO/POS provider, and PPO/POS referring provider before submission.

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