Harbor Choice Referral/authorization Form
ADVERTISEMENT
1Harbor Choice Referral/Authorization Form
“Non-urgent Prior Auth requests should be submitted a minimum of 5 days prior to the service date. Please allow a
minimum of 48 hours for review. You will be notified of decision when review is complete. “
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.
HEALTH PLAN: Harbor Choice
❏ ROUTINE ❏ URGENT
Health Plan Fax#: (866) 315-6314
❏ EMERGENCY
PATIENT INFO:
❏ OUT OF NETWORK
Patient Name: ____________________________________________________________
❏ REVISED REFERRAL
LAST
FIRST
M.I.
Original Fax Date: ____________
DOB: _____/_____/_____ Sex M ❏ F ❏ Phone # (____) ____-_____
Requested
Start Date: ____/____/_______
Member ID #:_______________________ Member Social Sec#: ___________________
Requested
OPTIONAL
End Date: ____/____/________
REFERRED BY:
ICD-10/DSM5/Diagnosis:___________
Physician Name: __________________________________________________________
LAST
FIRST
M.I.
Scope of referral
Address: ___________________________City__________________, State/Zip ________
❏ Consultation
❏ Diagnostic Testing
Provider#: _________________ ❏ PCP ❏ SCP ❏ HOSPITAL
Fax#: (____) ____-_____
❏ Follow-up
Contact Name: ___________________________________
Phone#: (____) ____-_____
Number of Visits: __________
REFERRED TO:
SPECIFIC SERVICES REQUESTED**
Provider Name: ___________________________________________________________
**Refer to specific plan instructions.
LAST
FIRST
M.I.
Certification/authorization guidelines
Address: ___________________________City__________________, State/Zip ________
must be followed.
❏ Behavioral Health
Specialty Type: _________________________ Provider/Facility#:___________________
❏ Dialysis
Fax#: (____) ____-_____ Phone#: (____) ____-_____
❏ DME/Prosthesis/Supplies
REFERRED TO LOCATION:
❏ Case Management
❏ Office ❏ Outpatient facility*** ❏ Inpatient ❏ 23 Hour observation
❏ Health Education
***
Note for outpatient facility, List CPT4 at right
❏ Home Care
❏ ER/Post Stabilization
❏ Other
Date of Service: ____/____/______
❏ Injections and IV Therapy
Facility Name: ____________________________________________________________
❏ Maternity Services:
Address: ____________________________City__________________, State/Zip_______
EDC: __________________
❏ Vaginal ❏ C-Section
*_________________________*
Facility#:
Required for ER/UCC, Therapy and Outpatient services.
❏ Lab/Pathology
COMMENTS/CLINICAL HISTORY:
❏ Radiology/Imaging
❏ Therapy:
Indicate # of visits: ________
Clinical Information Attached: ❏ Y / N ❏
# of Pages: _____
❏ Physical ❏ Cardiac Rehab
PHYSICIAN SIGNATURE: __________________________________________________
❏ Speech ❏ Occupational
The information contained in this form is privileged and confidential and is only for the use of the individual or
Visits/Week ______________
entities named on this form. If the reader of this form is not the intended recipient or the employee or agent
responsible to deliver it to the intended recipient, the reader is hereby notified that any dissemination,
❏ Surgery ___________ (CPT4 code)
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.
❏ Assistant Surgeon
HEALTH SERVICES RESPONSE:
❏ Approved as Requested
Enter CPT4/HCPS Codes here:
Authorization#: ______________________________
_____________ ______________
Expiration Date: ______________________________
_____________ ______________
Days Authorized: _____________________________
Number of Units (if applicable): ___________
❏ Medical Director Review
❏ Pending Info
❏ No Referral Needed
❏ Denied
❏ Approved with modification
NOTES: ____________________________________Signature: _______________________________________Date: ____/____/_____
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business