Texas Referral/authorization Form - Cfhp Health Services
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1Exhibit 4
CFHP Health Services
Texas Referral/Authorization Form
Fax Number:
210-358-6040 or
1-800-887-7974
Please fill out form completely in blue or black ink. Refer to instruction sheet.
This referral does not guarantee payment. Please contact health plan to verify member eligibility and covered benefits.
ο CHIP ο EPO ο HMO ο PCCM ο POS ο PPO ο W/C ο OTHER ________
ο ROUTINE ο URGENT
ο EMERGENCY
ο OUT OF NETWORK
ο REVISED REFERRAL
HEALTH PLAN NAME
________________________ DATE ____/____/____
:
ο NOTIFICATION ONLY
Health Plan Fax# (____)_____________
PATIENT INFO.
Requested
Patient name ______________________________________________________________
Start date ____/_______/_______
LAST
FIRST
MIDDLE INITIAL
Requested
End date _____/_______/_______
DOB ______/________/______
Sex Mο Fο Phone # (___ _)____________________
ICD-9/DSM4/Diagnosis_________
Member ID #____________________ Member Social Sec. # ______-_________-________
______________________________
OPTIONAL
Scope of referral
REFERRED BY
ο Consultation
ο Diagnostic Testing
Physician name __________________________________________________________
LAST
FIRST
M.I.
ο Follow-up
ο PCP ο SCP ο HOSPITAL
Number of visits _____
Provider # _________________________________
Fax # (______)____________________
Contact name __________________________ Phone # (_____)_________________
SPECIFIC SERVICES REQUESTED**
**Refer to specific plan instructions.
REFERRED TO
Certification/authorization guidelines must
Provider name ____________________________________________________________
be followed.
ο Behavioral Health
LAST
FIRST
M.I.
Specialty type ___________________________ Provider/Facility # _________________
ο Dialysis
ο DME/Prosthesis/Supplies
Fax # (_____)____________________ Phone # (_____)_______________________
ο Case Mgmt. ___________________
Provider City ____________________________, Texas
_____________________________
ο Health Educ. __________________
REFERRED TO LOCATION
_____________________________
ο Home Care
ο Office ο Outpatient facility*** ο Inpatient ο 23 Hour observation
ο Injections and IV Therapy
***
Note for outpatient facility, List CPT4 at right
ο ER/Post Stabilization ο Other
ο Maternity Services:
Date of service _______/________/______
Facility name _____________________________________________________________
EDC ________________________
ο Vaginal ο C-Section
*
*
Facility #
_____________________________
Required for ER/UCC, Therapy and Outpatient services.
ο Lab/Pathology
COMMENTS/CLINICAL HISTORY
__________________________________________
ο Radiology/ Imaging
ο Therapy:
Indicate # of visits ________
________________________________________________________________________
ο Physical ο Cardiac Rehab
ο Speech
ο Occupational
________________________________________________________________________
Visits/Week _____
________________________________________________________________________
Clinical information attached: ο Y / N ο
ο Surgery ____________(CPT4 code)
# of pages _____
ο Assistant Surgeon
PHYSICIAN SIGNATURE-
_________________________________________________
TO AUTHORIZE ONLY (OR OTHER) SPECIFIC
The information contained in this form is privileged and confidential and is only for the use of the individual or
SERVICES, INCLUDE CPT4 /MEDICAID LOCAL OR
entities named on this form. If the reader of this form is not the intended recipient or the employee or agent
HCPCS CODES HERE.
responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination,
_____________
_____________
distribution, or copying of this communication is strictly prohibited If this communication has been received in
error, the reader shall notify sender immediately and shall destroy all information received.
_____________
_____________
HEALTH SERVICES RESPONSE
_____________
_____________
ο Approved as requested
Authorization # ___________________
Expiration date ______/______/______
Days authorized _____
ο Medical Director Review
ο Pending Info. ο No referral needed
ο Denied
ο Approved with modification
NOTES ________________________________________________Signature _____________________________Date: ___/___/_____
Revised 12-15-00
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