Get the free Out-of-Network Referral Request Form - SIHO - siho

Out-of-Network Referral Request Form Phone: 800.553.6027 Please complete form and fax to: 812.378.7054 or 317.860.3601 Patient Name: Date of Birth: / / Patient ID Number: Diagnosis (Include ICD9 Codes):

How to fill out out-of-network referral request form

1. To fill out an out-of-network referral request form, you first need to obtain the form itself. This form is typically provided by your insurance company or healthcare provider. Contact them to request a copy if you don't already have one.
2. Once you have the form, carefully read all the instructions and requirements listed. Make sure you understand what information is needed and how to properly fill out the form.
3. Start by providing your personal information, including your full name, date of birth, address, and contact information. This ensures that the referral request is associated with your medical records.
4. Next, provide details about your current healthcare provider. This includes their name, contact details, and any relevant identification numbers or codes. You may also need to provide information about their specialty and office location.
5. In the referral section of the form, specify the details of the out-of-network provider you wish to be referred to. This includes their name, contact information, and the reason for the referral.
6. Provide any supporting documentation required by the form, such as documentation from your healthcare provider explaining the medical necessity of seeking out-of-network care.
7. If applicable, provide information regarding your insurance coverage for out-of-network services. This may include your insurance policy number, group number, and any other relevant details.
8. Review the completed form for accuracy and ensure that all required fields have been filled. Double-check that you have provided all the necessary supporting documents.
9. Once you are satisfied with the completed form, submit it to the appropriate party. This may involve submitting it directly to your insurance company, your healthcare provider, or both. Follow any additional instructions provided to ensure that your referral request is properly processed.

Who needs an out-of-network referral request form?

1. Individuals who have health insurance coverage that requires obtaining a referral before seeking care from an out-of-network healthcare provider may need this form. This requirement can vary depending on the specific insurance plan.
2. Patients who have previously been receiving care from an in-network provider but now need to see an out-of-network provider for specialized treatment or services may need to fill out this form.
3. Individuals who are seeking reimbursement for out-of-network services already received may also need to complete an out-of-network referral request form as part of the reimbursement process. This ensures that the services are deemed medically necessary and eligible for coverage.

Remember to consult your insurance provider and healthcare provider for specific guidance and requirements related to filling out the out-of-network referral request form.

For pdfFiller’s FAQs

What is out-of-network referral request form?

The out-of-network referral request form is a document that allows members to request approval for medical services from healthcare providers who are not in the insurance plan's network.

Who is required to file out-of-network referral request form?

Members who wish to receive medical services from out-of-network providers are required to file the out-of-network referral request form.

How to fill out out-of-network referral request form?

To fill out the out-of-network referral request form, members must provide their personal information, details of the requested service, reasons for seeking out-of-network care, and relevant medical records.

What is the purpose of out-of-network referral request form?

The purpose of the out-of-network referral request form is to obtain authorization from the insurance plan for medical services provided by out-of-network providers, ensuring coverage and reimbursement.

What information must be reported on out-of-network referral request form?

The out-of-network referral request form must include member's personal information, details of the requested service, reasons for seeking out-of-network care, and relevant medical records.

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