Physician Referral Form - Vermont
Please check “yes” or “no” to all of the following questions:
Is this service obtainable in Vermont?
Have efforts been made to find a closer provider?
Does the requested physician possess special expertise?
Is it medically necessary for this physician to treat this patient?
Does the patient have a history with this specific provider?
Can another physician take over this case if a history does exist?
If this is an out-of-state/out-of-network request, is a Clinical prior
authorization in place?
Please describe the specific service or medical care that this member needs a ride to:
Is there a medical reason for someone to accompany the member on this trip?____________________
If necessary, please add any further information: ___________________________________________
Print name of Doctor or Doctor’s Staff providing information Phone
Signature of Doctor or Doctor’s Staff providing information Date
Physician Referral Form - Vermont PDF
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