Managed Care Referral Form

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Managed Care Referral Form
Section 1. PATIENT INFORMATION
*Patient ID no. *Date of birth (MM/DD/YYYY)
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*Patient last name *Patient first name MI
Policyholder last name Policyholder last name MI
Section 2. REFERRING PHYSICIAN INFORMATION
*Provider last name *Provider first name MI
Service address
*Empire provider ID or NPI Phone no.
Section 3. REFERRING TO INFORMATION
*Specialist last name *Specialist first name MI
Service address
*Empire provider ID or NPI Phone no.
Section 4. AUTHORIZATION INFORMATION
Referrals are valid for 90 days from the service start date unless
otherwise specified. Please remember Authorized Services are subject
to Limitations/Exclusions of Contract.
No. of visits *Service start date (MM/DD/YYYY) *Service end date (MM/DD/YYYY)
Referral reason/remarks/limitations
*Signature of referring physician *Date (MM/DD/YYYY)
PO BOX 1407, Church Street Station
New York, New York 10008- 1407
Fax no. 1-800-522-5793
www.empireblue.com
Referrals are not valid for the following services; please contact Empire Medical Management at 1-800-441-2411 for approval of these services:
} Non-participating Provider’s
} Emergency/Maternity Admissions
} Empire Baby Care
} Inpatient Admission to Hospital/Facilities
} Home Care, Hospice, Private Duty Nursing (at home)
} Surgery not performed in doctor’s office
Health Plans that require a referral to an Empire participating provider are:
} HMO
} Child Health Plus
} Healthy NY
} Direct Pay HMO
} Direct Pay HMO/POS
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
12895NYPEN 3/10
Reference no.
N
PCP’s Tracking no. (Optional/not required)
* Required field. If any required field is missing, the referral will not be accepted.
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