PA Gateway Health Plan Referral Form 2013-2025 free printable template

Mail to Gateway Health Plan P. O. Box 69360 Harrisburg PA 17106-9360 GATEWAY HEALTH PLAN REFERRAL FORM CAHL000705 For claims payment purposes each referral you issue requires a NEW form to be downloaded and printed. Just print complete and mail to the address on the form. PRIMARY CARE INFORMATION PCP Name PCP Address Automated telephone referrals may be done through Gateway s DIVA/EVS line at 1-800-642-3515. No referral needed when member is refe...

How to fill out PA Gateway Health Plan Referral Form

How to fill out PA Gateway Health Plan Referral Form

1. Obtain the PA Gateway Health Plan Referral Form from your healthcare provider or online.
2. Fill in the patient’s information including name, date of birth, and insurance details.
3. Provide the referring provider's information including name, contact number, and NPI number.
4. Complete the details of the specialist or service to whom the patient is being referred.
5. Specify the reason for the referral and any relevant medical history.
6. Sign and date the form to validate the referral.
7. Submit the form to the appropriate contact as instructed by the health plan.

Who needs PA Gateway Health Plan Referral Form?

1. Patients who require specialist services covered by the PA Gateway Health Plan.
2. Healthcare providers who need to refer patients for specialized care.

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What is PA Gateway Health Plan Referral Form?

The PA Gateway Health Plan Referral Form is a document used to request referrals for medical services and procedures within the PA Gateway Health Plan framework.

Who is required to file PA Gateway Health Plan Referral Form?

Providers involved in the care of patients enrolled in the PA Gateway Health Plan are required to file the PA Gateway Health Plan Referral Form when referring patients for specialized services.

How to fill out PA Gateway Health Plan Referral Form?

To fill out the PA Gateway Health Plan Referral Form, providers need to include patient information, details of the requested referral, and the specificity of the services needed, ensuring all required sections are completed accurately.

What is the purpose of PA Gateway Health Plan Referral Form?

The purpose of the PA Gateway Health Plan Referral Form is to ensure proper authorization of medical services, maintain care coordination, and facilitate communication between providers.

What information must be reported on PA Gateway Health Plan Referral Form?

The information that must be reported on the PA Gateway Health Plan Referral Form includes the patient's personal information, identification numbers, details of the services being referred, and the referring physician's information.