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Managed care referral form

Managed care referral form 2026

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The document is a Managed Care Referral Form that collects patient and physician information for referrals to specialists. It outlines the necessary details such as patient ID, provider IDs, service dates, and authorization information. The form specifies limitations on valid referrals and provides contact information for services requiring prior approval. It emphasizes the importance of completing all required fields to ensure acceptance of the referral.

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Click ‘Get Form’ to open the managed care referral form in the editor.
Begin with Section 1: PATIENT INFORMATION. Fill in the required fields such as Patient ID number, date of birth, and both last and first names of the patient and policyholder.
Proceed to Section 2: REFERRING PHYSICIAN INFORMATION. Enter the provider's last name, first name, service address, Empire provider ID or NPI, and phone number.
In Section 3: REFERRING TO INFORMATION, input the specialist's last name, first name, service address, Empire provider ID or NPI, and phone number.
Move to Section 4: AUTHORIZATION INFORMATION. Note that referrals are valid for 90 days. Fill in the number of visits, service start and end dates, referral reason/remarks/limitations. Ensure you sign and date this section.

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