Get the free Referral Authorization Form - vivahealth.com

417 20th Street North Suite 1100 Birmingham, AL 35203Fax Number: (205) 5587506 Coverage Criteria: The patient has tried, failed and/or been intolerant (continues to have angina)to a trial of therapy

How to fill out referral authorization form

How to fill out referral authorization form

1. Step 1: Obtain the referral authorization form from the appropriate source.
2. Step 2: Read through the form thoroughly to understand the requirements and instructions.
3. Step 3: Fill out the patient's personal information accurately, including name, date of birth, address, and contact details.
4. Step 4: Provide details of the referring physician or healthcare provider, including name, contact information, and any necessary identification numbers.
5. Step 5: Specify the reason for referral and the requested services or treatments.
6. Step 6: If applicable, include any supporting documentation or medical records that might be required.
7. Step 7: Review the completed form to ensure all necessary information is provided and legible.
8. Step 8: Sign and date the referral authorization form.
9. Step 9: Submit the form to the designated recipient or follow any additional submission instructions outlined on the form.
10. Step 10: Keep a copy of the filled-out form for your records.

Who needs referral authorization form?

1. Individuals who require specialized medical services or treatments that necessitate a referral from their primary care physician or healthcare provider.
2. Healthcare providers who need to authorize a referral for their patients to access specialized services or treatments.
3. Medical insurance companies or administrators who require referral authorization as part of the claim process.

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