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OUT-OF-NETWORK REFERRAL FORM Fax to Group Health Trust 262-781-0026 Group Name Fond du Lac County Group Number WCA0020 Employee/Member Name Member ID Patient Name Name of PPO Referring Physician Clinic/Hospital Name of Non-PPO Physician Being Referred To Reason for Referral Date of Service Referring Physician s Signature Date The PPO level of benefits will be payable for the Non-PPO Providers if the above Referral Form is completed and signed by the Referring PPO Provider.
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How to fill out out-of-network referral form
How to fill out out-of-network referral form
01
Read the form carefully to understand the information needed.
02
Gather all the required documents, such as medical bills and doctor's notes.
03
Provide your personal information accurately, including your name, address, and contact details.
04
Clearly indicate the reason for seeking out-of-network care and the specific services or treatments required.
05
Attach all supporting documentation, including any pre-approvals or prior authorizations if applicable.
06
Fill out any additional sections or fields as instructed on the form.
07
Review the completed form for accuracy and completeness.
08
Submit the filled out-of-network referral form to the respective department or insurance provider.
09
Keep a copy of the filled form for your records.
Who needs out-of-network referral form?
01
Individuals who have health insurance coverage that allows out-of-network care.
02
People who require medical treatments or services from healthcare providers outside of their insurance network.
03
Patients seeking specialized or unique medical treatments that are unavailable within the network.
04
Those recommended by their primary care physician to seek specialized care outside of the network.
05
Individuals who have received prior authorization from their insurance plan for out-of-network care.
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What is out-of-network referral form?
An out-of-network referral form is a document that allows a patient to seek medical services from a healthcare provider that is not in their insurance network.
Who is required to file out-of-network referral form?
Patients who wish to receive medical services from an out-of-network provider are required to file an out-of-network referral form.
How to fill out out-of-network referral form?
To fill out an out-of-network referral form, the patient must provide their personal information, details of the out-of-network provider, and reason for seeking services outside of the network.
What is the purpose of out-of-network referral form?
The purpose of an out-of-network referral form is to obtain approval from the insurance company to receive medical services from a provider that is not in the network.
What information must be reported on out-of-network referral form?
The out-of-network referral form must include the patient's name, insurance information, details of the out-of-network provider, and reason for seeking services outside of the network.
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