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One Monarch Place Suite 1500 Springfield, MA 01144-1500 413.787.4000, Ext. 5028 800.842.4464 Behavioral Health Department BH Fax: 413.233.2800 PAGE 1 OF 2 REFERRAL TO OUT-OF-NETWORK PROVIDER INSTRUCTIONS

How to fill out referral to out-of-network provider

How to fill out referral to out-of-network provider?

1. Obtain a copy of the referral form from your insurance company or download it from their website.
2. Fill out your personal information, such as name, address, and contact details, accurately and legibly.
3. Provide the details of the out-of-network provider you wish to see, including their name, specialty, and contact information.
4. Clearly state the reason for requesting a referral to an out-of-network provider, providing any relevant medical history or documentation to support your request.
5. If required, include the date and duration of the referral, specifying the number of visits or sessions needed.
6. Review the completed referral form for any errors or missing information, ensuring all necessary fields are filled out accurately.
7. Submit the referral form to your primary care physician or the designated authority specified by your insurance company.

Who needs a referral to an out-of-network provider?

1. Individuals who have health insurance plans that require a referral to seek care from out-of-network providers.
2. Patients who wish to receive services or treatments from a healthcare provider who is not part of their insurance company's network.
3. Individuals who have been recommended by their primary care physician to receive care from a specialist or facility that is out-of-network.

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What is referral to out-of-network provider?

A referral to an out-of-network provider is a request from a patient's primary care physician for the patient to receive medical care from a provider who is not in the patient's insurance network.

Who is required to file referral to out-of-network provider?

The primary care physician or the referring physician is typically required to file a referral to an out-of-network provider.

How to fill out referral to out-of-network provider?

The referral form should include the patient's personal information, the reason for the referral, the name and contact information of the out-of-network provider, and any other relevant details.

What is the purpose of referral to out-of-network provider?

The purpose of a referral to an out-of-network provider is to ensure that the patient receives specialized medical care that may not be available within their insurance network.

What information must be reported on referral to out-of-network provider?

The referral must include the patient's personal information, the reason for the referral, the name and contact information of the out-of-network provider, and any supporting documentation or medical records.