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Passport referral form

Passport referral form 2025

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The document is a Referral Form for Passport Health Plan members, detailing the necessary information and guidelines for referrals from a Primary Care Provider (PCP) to participating specialists or Urgent Care Centers. It outlines the conditions under which referrals are valid, including the requirement for prior authorization for non-participating providers, and specifies that services rendered without a referral will not be covered. The form includes sections for member details, referred provider information, diagnosis codes, and approval for visits.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the form for parent authorization for passport?

Therefore, when you do not receive your U.S. passport book or card in the mail, you must submit form DS-86, Statement of Non-Receipt of a U.S. Passport. The information that you provide on this form will be entered into the Consular Lost and Stolen Passport System.

Who can be your passport referee?

Unless you qualify for a passport renewal, youll need a referee or guarantor. Your referee or guarantor must: be an adult Australian citizen who has known you for more than one year, and. cannot be any kind of relative, in a de facto relationship with you, or living at the same address as you.

Who qualifies as a guarantor?

A guarantor is a person who guarantees your identity. This person must have known you for at least 2 years and well enough to confirm the information in your application is true.

How do I get a passport for my child with an absent father?

Parental/Guardian Consent (required for minors under 16): If one parent/guardian cannot appear in person with the child to apply for the passport, they must complete the Form DS-3053 Statement of Consent. You must submit the completed form with the childs passport application.

Who can references be on a passport?

A boyfriend, girlfriend or romantic partner can be a reference if youre not in a common-law relationship. If your marriage or common-law relationship has ended, your former spouse or partner can serve as a reference.