Passport referral form 2026

1. Click ‘Get Form’ to open the passport referral form in the editor.
2. Begin by entering the Member ID#, Last Name, First Name, Date of Birth, Phone, and Alternate Contact Information. Ensure accuracy as this information is crucial for processing.
3. Fill in the Primary Care Provider (PCP) Group Name and ID Number. This identifies the referring provider responsible for the member's care.
4. In the section labeled 'This member is being referred to', provide details about the referred provider including their name, ID number, specialty type, and address. This ensures that the referral reaches the correct specialist.
5. Indicate if this referral is related to an EPSDT screen by selecting 'Yes' or 'No'.
6. Select one of the options regarding the type of referral and specify any limitations on visits. This helps clarify what services are authorized.
7. Finally, ensure that you sign and date the form before submission. Send a copy to Passport Health Plan and provide copies to both the specialist and member.

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