Managed Care Referrals Form - Blue Cross Blue Shield Of Michigan

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MANAGED CARE REFERRALS
BCBSM, Inc. and its Affiliates
P.O. Box 64179, St. Paul, MN 55164-0179
Telephone (651) 662-5200 or 1-800-262-0820
Fax (651) 662-6860 (Use only one side of form)
Clinic name ______________________________________
Contact person __________________________________
Clinic address __________________________________________________________________________________________
Clinic provider number__________________
Phone # (_______)______________
Fax # (
)______________
National Provider number____________________
Patient’s name
Patient’s date of birth ___________________
ID number (
___ ___ ___) ___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___)
alpha
(member #
Your clinic physician’s individual number (7 digits) ___ ___ ___ ___ ___ ___ ___
Your clinic physician's name ________________________________________________________________________
Clinic/hospital provider number that patient is being referred to ___ ___ ___ ___ ___ ___ ___
Clinic/hospital name that patient is being referred to _____________________________________________________
Clinic/hospital Tax ID# that patient is being referred to ______________________________________________________
Clinic/hospital address that patient is being referred to ______________________________________________________
Type of visit (circle one)
______________________________________________________
MD visit
OP visit (requires ICD-9 procedure code): ___ ___ . ___ ___
or CPT code: ___ ___ ___ ___ ___
Date of service: from _____ /_____ / __________ to _____ /_____ / __________ For ____ Days
Number of visits approved __________
ICD-9 diagnosis ___ ___ ___ . ___ ___
Comment codes* (circle no more than 3) CON
DIA
DXL
HOS
LAB
OUT
REP
STA
THP
XRY
Patient’s name
Patient’s date of birth ___________________
ID number (
___ ___ ___) ___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___)
alpha
(member #
Your clinic physician’s individual number (7 digits) ___ ___ ___ ___ ___ ___ ___
Your clinic physician's name ________________________________________________________________________
Clinic/hospital provider number that patient is being referred to ___ ___ ___ ___ ___ ___ ___
Clinic/hospital name that patient is being referred to _____________________________________________________
Clinic/hospital Tax ID# that patient is being referred to ______________________________________________________
Clinic/hospital address that patient is being referred to ______________________________________________________
Type of visit (circle one)
______________________________________________________
MD visit
OP visit (requires ICD-9 procedure code): ___ ___ . ___ ___
or CPT code: ___ ___ ___ ___ ___
Date of service: from _____ /_____ / __________ to _____ /_____ / __________ For ____ Days
Number of visits approved __________
ICD-9 diagnosis ___ ___ ___ . ___ ___
Comment codes* (circle no more than 3) CON
DIA
DXL
HOS
LAB
OUT
REP
STA
THP
XRY
*
CON Referral authorized for one consultation only
OUT Outpatient services only
DIA Diagnostic evaluation only
REP Send thorough written report when consultation is complete
DXL Lab or X-ray services not authorized
STA Please send periodic status reports on this patient
HOS Do not hospitalize without primary care authorization
THP No therapy services are authorized
LAB No lab services are authorized
XRY No X-ray services are authorized
X12388 – R8 (10/08)

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