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Managed care referral form 2026
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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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