01. Edit your form online
Type text, add images, blackout confidential details, add comments, highlights and more.
Passport referral form 2026
Here's how it works
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out passport referral form with our platform
Ease of Setup
DocHub User Ratings on G2
Ease of Use
DocHub User Ratings on G2
- Click ‘Get Form’ to open the passport referral form in the editor.
- 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.
- Fill in the Primary Care Provider (PCP) Group Name and ID Number. This identifies the referring provider responsible for the member's care.
- 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.
- Indicate if this referral is related to an EPSDT screen by selecting 'Yes' or 'No'.
- Select one of the options regarding the type of referral and specify any limitations on visits. This helps clarify what services are authorized.
- 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.
Start using our platform today for free to streamline your document editing and form completion!
Security and compliance
At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.
Related links
Form Finder ; DS-0011 (PDF), (PDF) Application for a U.S. Passport ; DS-0060, Affidavit Regarding A Change of Name ; DS-0063, Education Allowance Questionnaire ; DSRead more
Primary evidence of sole authority to apply, OR. Parental identification. WHERE TO SUBMIT THIS FORM: 1. PROOF OF U.S. CITIZENSHIP. 2. PROOF OF IDENTITY. 3Read more
by JB Doe 17. Add the 2-Digit Qualifier in Box 17 for the referring (DN), ordering (DK) or supervising (DQ) provider. (Required for these provider types only). No Change.Read more