Health Advantage Specialty Referral Form

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Health Advantage Specialty Referral
(Use only for IN-NETWORK Referrals)
(To request OUT-OF-NETWORK referrals, use the OON Referral Form)
Attn. Member: This authorizes the following specialist to forward to your Primary Care
Physician medical information to assist with coordination and continuity of your care.
Member Name: ________________________________ID#______________________
In-Network Specialist:____________________________________________________
Reason for Referral:______________________________________________________
Restrictions: ____________________________________________________________
Date Span: __________________to_____________Number of Visits______________
PCP Name ______________________________________________________________
(Print Name)
(Signature)
(Date)
HA/ABCBS PCP Provider #
National Provider Identifier#
_______________________________________
*Specialist should indicate either the BCBS provider # or the NPI # in field 23 on
the HCFA 1500 claim form.
Specialty Referral services are subject to member eligibility and the benefits available through the
Member's plan, therefore, this referral should not be considered a guarantee of payment.
IMPORTANT INFORMATION FOR THE PHYSICIAN AND MEMBER
SPECIALIST: Please submit to the referring Primary Care Physician a summary of findings
to include diagnosis(es) and test results, medications and other treatment plans to assist in the
continuity and coordination of care. Please contact the PCP if additional referrals are
recommended.
X-ray and lab results may be available. To avoid duplication, please check with the Primary
Care Physician.
Information regarding this process is available in the Health Advantage Provider Manual or
you may contact Customer Service in the Regional Office.
OUT-OF-NETWORK REFERRALS REQUIRE REVIEW AND APPROVAL FOR BENEFIT AUTHORIZATION
FOR OON REFERRALS, PLEASE USE THE OUT-OF-NETWORK REFERRAL REQUEST FORM
FAX OUT-OF-NETWORK REQUESTS TO (501)378-6647
To verify eligibility and benefits, please call the Customer Service # on the Member's ID
card. Have the Member's ID # ready.

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