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SPECIALIST REFERRAL AND IDENTIFICATION FORM Please complete this form in full. Fax request to 18009732321. If you would like to submit notifications online, you can visit www.quantumhealth.com/providers.

How to fill out specialist referral and pre-notification

How to Fill Out Specialist Referral and Pre-notification:

1. Start by obtaining the necessary forms for specialist referral and pre-notification from your healthcare provider or insurance company. These forms are typically available online or can be obtained through your doctor's office.
2. Fill in your personal information, including your name, address, phone number, and insurance information. Make sure to double-check the accuracy of this information to avoid any delays or issues with your referral or pre-notification.
3. Provide the name and contact information of the specialist you are being referred to. It is essential to include their full name, specialty, and office address or phone number to ensure proper communication and coordination of care.
4. Indicate the reason for the referral by clearly describing your symptoms, medical condition, or the specific type of specialist requested. Be as detailed as possible to provide the necessary context for the referral. If you have any relevant medical records or test results, attach copies to support your referral.
5. Ensure that your primary care physician has signed and dated the referral form. In some cases, your doctor may need to provide additional notes or justification for the referral, particularly if you are seeing a specialist outside of your network.
6. Review the pre-notification section of the form carefully. This section typically requires you to provide details about the proposed treatment or procedure, including the diagnosis, anticipated dates, and any supporting documentation from your healthcare provider.
7. If your insurance plan requires pre-authorization or pre-certification for the specialist visit, make sure to follow the specific instructions provided. This may involve contacting your insurance company directly or submitting additional documentation, such as medical records or test results.

Who Needs Specialist Referral and Pre-notification:

1. Individuals who are enrolled in a health insurance plan that requires referrals or pre-notification for specialist visits. Some insurance plans, particularly managed care or HMO plans, require patients to obtain a referral from their primary care physician before seeing a specialist.
2. Patients who need to see a specialist for a specific medical condition or treatment. Specialist referrals are typically required for services beyond the scope of primary care, such as consultations with a dermatologist, cardiologist, or orthopedic surgeon.
3. Individuals seeking coverage for certain procedures or treatments that require pre-authorization or pre-certification by their insurance company. This process helps determine the medical necessity and eligibility for coverage for specific services.

It is essential to check your insurance plan's guidelines and requirements to determine if specialist referrals and pre-notification are necessary in your case. Each insurance plan may have different policies regarding referrals and pre-authorization, so it is crucial to follow the specific instructions provided by your healthcare provider and insurance company.

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What is specialist referral and pre-notification?

Specialist referral and pre-notification is the process of requesting permission from a primary care physician to see a specialist and notifying the insurance company of the upcoming specialist visit.

Who is required to file specialist referral and pre-notification?

Patients are required to file specialist referral and pre-notification before seeing a specialist.

How to fill out specialist referral and pre-notification?

Patients can fill out specialist referral and pre-notification forms provided by their insurance company or primary care physician.

What is the purpose of specialist referral and pre-notification?

The purpose of specialist referral and pre-notification is to ensure that the visit to the specialist is necessary and covered by insurance.

What information must be reported on specialist referral and pre-notification?

Information such as the reason for the specialist visit, the specialist's name, date of appointment, and insurance information must be reported on specialist referral and pre-notification forms.