Fillable Student Health Center Referral Form (Page 2 of 2) in pdf

Student Health Center Referral Form Page 2

Download a blank fillable Student Health Center Referral Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Student Health Center Referral Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Students: Bring a copy of this form to provider and keep a copy for your files.

Only one referral form is required per illness, even if the student sees the physician multiple times or is referred by that physician to another health care

provider for the same illness. However, if the physician refers the student to another provider for a different illness, the student must obtain a new referral form

at the Student Health Center.

Note to Providers:

This student is enrolled in a GeoBlue Blue Cross group plan with access to the Blue Cross Blue Shield National PPO Network.

With this referral form, the copayment is waived.

Providers will be paid for covered services in accordance with the Provider Network Agreement once the claim and this form are received by the GeoBlue

claims department.

Please indicate the referral from the Student Health Center in Referring Physician

field on the claim form submitted to the Local Blue Cross or Blue Shield plan.

A copy of the completed form should be submitted as noted at the bottom of this form.

Customer Service

1.844.268.2686

If not filing form electronically, submit this Referral Form to:

GeoBlue

P.O. Box 21974 Eagan, MN 55121

-or-

Referral Form Submission Fax:

1.610.482.9623