Gateway Health Plan OB/GYN Referral Form 2013 free printable template

Mail to: Gateway Health Plan? P.O. Box 69360 Harrisburg, PA 17106-9360 CD2N465841 ? GATEWAY HEALTH PLAN OB/GUN REFERRAL FORM For claims payment purposes each referral you issue requires a NEW form

How to fill out Gateway Health Plan OBGYN Referral Form

How to fill out Gateway Health Plan OB/GYN Referral Form

1. Begin by obtaining the Gateway Health Plan OB/GYN Referral Form either online or from your healthcare provider.
2. Fill out the patient's personal information including name, date of birth, and insurance details.
3. Provide the referring physician's information, including name, contact number, and practice address.
4. Indicate the reason for the referral by checking the appropriate boxes or writing a brief description.
5. Fill in any relevant medical history, including previous treatments or conditions related to OB/GYN care.
6. Ensure that the form is signed by the referring physician to validate the referral.
7. Submit the completed form to the Gateway Health Plan, either electronically or via fax, following their submission guidelines.
8. Keep a copy of the submitted form for your records.

Who needs Gateway Health Plan OB/GYN Referral Form?

1. Patients who require specialized OB/GYN care and need a referral from their primary care physician.
2. Individuals enrolled in the Gateway Health Plan who are seeking OB/GYN consultations or treatments.

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What is Gateway Health Plan OB/GYN Referral Form?

The Gateway Health Plan OB/GYN Referral Form is a document used to authorize referrals for patients seeking specialized obstetric and gynecological care within the Gateway Health Plan network.

Who is required to file Gateway Health Plan OB/GYN Referral Form?

Healthcare providers, particularly primary care physicians and OB/GYNs, are required to file the Gateway Health Plan OB/GYN Referral Form when referring patients for specialized services.

How to fill out Gateway Health Plan OB/GYN Referral Form?

To fill out the Gateway Health Plan OB/GYN Referral Form, providers should ensure that all patient information, including demographics and medical history, is accurately entered. They must specify the reason for the referral, the requested specialist, and any relevant clinical information.

What is the purpose of Gateway Health Plan OB/GYN Referral Form?

The purpose of the Gateway Health Plan OB/GYN Referral Form is to facilitate the process of obtaining necessary specialized care for patients while ensuring that care is coordinated and authorized by the insurance plan.

What information must be reported on Gateway Health Plan OB/GYN Referral Form?

The information required on the Gateway Health Plan OB/GYN Referral Form includes patient demographics, the referring provider's information, the specialist's details, the reason for referral, and any pertinent medical history or notes.