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