Primary Care Physician Referral Form For Aetna Members

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Primary Care Physician Referral Form
For Aetna Members Only
To be completed by specialty physician office. Please print clearly.
Complete name of specialist who is referring the patient:
First:
Last:
Specialist’s phone number: _______________________________________
Complete name of MGO primary care physician to whom you are referring the patient:
First:
Last:
Patient’s Name: ________________________________________________________________
Patient’s Address: ______________________________________________________________
_______________________________________________________________
Patient’s Phone Number: _______________________________________
Is this patient currently insured by Aetna? Yes ______________ No _________________
Please fax this form to OhioHealth Group at 614-566-0421. You will be given credit for making
the referral and the information will be faxed to the primary care physician to whom you have
referred the patient.
Information for Primary Care Physicians
This patient has been referred to you because he or she does not have an established relationship with a
primary care physician. This patient is insured by Aetna and has received care from an MGO specialty
care physician who participates in the Aetna PHO contract. The specialist has referred this patient to you
as part of MGO’s pay for quality program with Aetna.
You are being provided information to assist you if you wish to contact this patient and encourage him or
her to schedule an appointment. You are not required to contact the patient, however we do ask that if the
patient contacts your office you accept them as a new patient.
If you are not accepting new patients and you would like to have your name removed from the list of
MGO primary care physicians who are accepting new Aetna patients please call Matt Barrett, MGO
Director of PHO Contracts at 614-223-3333.

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