PCP REFERRAL AUTHORIZATION FORM

PCP REFERRAL AUTHORIZATION FORM

FOR HMO PLANS ONLY
Instructions: Primary Care Physician must submit PCP Referral Authorization Form to NetCare for review prior to referring patient for the scheduled consult/visit.

NetCare's HealthCare Management Department will notify the PCP and the Member of the deicision within two (2) business days after receiving request.

For immediate review of urgent referrals, please call NetCare's HealthCare Management Department at (671) 472--3610 ext. 245.
Primary Care Physician:
PCP Name*
Clinic Name*
Phone/Fax Number*
Please enter a valid phone number.
Email*
example@example.com
Date of Referral*

MonthDayYear
Date
Referred to Netcare Provider:
Specialist Name
Clinic Name
Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone/Fax Number
Please enter a valid phone number.
Date of Service

MonthDayYear
Date
Patient Information
Patient Name*

First NameLast Name
Policy Number*
Date of Birth*

MonthDayYear
Date
Telephone Number*
Please enter a valid phone number.
REASON FOR REFERRAL
Authorization Letter
Dear Colleague:
My office is referring the above named member for reasons noted below:

Single consultation visit for opinion and recommendation only.Number of additional visits.For diagnostic procedures, please request Prior Authorization from NetCarePlease keep me informed of patient's progress
Please specify number of additional visits. If not, three (3) visits will be authorized.
Please call me if you would like to proceed further than this initial authorization. Netcare will not cover any service or procedure which are not pre-authorized. You must cont me and NetCare prior to any procedure or hospital admission. All referrals expire sixty (60) days from date of first referred service. Thank you for seeing this patient.
Signature of Primary Care Physician*

Clear
NETCARE WILL NOT BE RESPONSIBLE FOR PAYMENT OF NON-COVERED SERVICES EVEN IF RECOMMENDED BY THE PRIMARY CARE PHYSICIAN (PCP) OR SPECIALIST. (See Group Service Agreement or call NetCare Member Services Department).
Should be Empty:

PCP REFERRAL AUTHORIZATION FORM

Primary Care Physician:

Referred to Netcare Provider:

Patient Information

Authorization Letter