Uniform Consultation Referral Form

Uniform Consultation Referral Form - Maryland Uniform Consultation Referral Form PDF Maryland Uniform Credentialing Form PDF Medical Benefit Drug Prior Authorization Form PDF Member Pre Service Appeal Form PDF New Prior Authorization Form PDF Required Form as of 4 1 21 Please refer to Pharmacy PA Forms for medication requests Newborn Notification Form PDF

Maryland Uniform Consultation Referral Form Date of Referral Patient Information Name Last First MI Date of Birth MM DD YY Phone Member Site Carrier Information Name Maryland Physicians Care MCO Address 1 1201 Winterson Rd 4th Floor Linthicum MD 21090 Phone Number 800 953 8854 Name Last First MI S pecialty

Uniform Consultation Referral Form

Uniform Consultation Referral Form

Primary care providers must use the Maryland Uniform Consultation Referral Form (PDF) when referring MedStar Family Choice members to Specialists. The forms are valid for 180 days. Complete the referral form in its entirety and the authorizing signature box must be signed by the PCP.

Submit the completed Uniform Consultation Referral Form to CareFirst BlueChoice applies to PCP only by fax to 410 505 6160 or 1 800 354 8205 Forms can also be mailed to Mail Administrator P O Box 14116 Lexington KY 40512 4116 This is not the correct form to refer a member for laboratory or radiology services

Span Class Result Type

Primary or Requesting Provider Consultant Facility Provider Referral Information Referral certification is not a guarantee of payment Payment of benefits is subject to a member s eligibility on the date that the service is rendered and to any other contractual provisions of the plan carrier

Free Printable Maryland Uniform Consultation Referral Form Printable Forms Free Online

Uniform Consultation Referral Form Date of Referral Patient Information Name Member Site Carrier Information Address Fax Primary or Requesting Provider Consultation with Specific Procedures specify o Laboratory o Inpatient Hospital o Specific Treatment o Extended Care Facility o

Provider Forms Maryland Physicians Care

Provider Inquiry Resolution Form Do not use this form for Appeals or Corrected Claims This form is to be used for Inquiries only Provider Refund Submission Form Uniform Consultation Referral Form The editable version of this form is available by logging into the Provider Portal

Suggested Format For A Referral For Consultation Form Download Scientific Diagram

A If a carrier requires a covered person to have a written referral in order to receive services the carrier shall use the uniform consultation referral form as defined in Regulation 02B 6 of this chapter B The carrier may not impose as a condition of coverage a requirement to

To help save you time and improve the referral submission process, we've also created a job-aide to assist you when submitting referrals for these products. We appreciate your patience as we develop new online tools to help you continue to coordinate and manage care effectively. Questions? Please contact the Provider Services line at 800-842 ...

Patient Referral Specialist MedStar Family Choice

The Maryland Uniform Dental Consultation Referral Form shall read as follows Click here to view Image B The electronic equivalent of the uniform consultation referral form is as follows Notes Md Code Regs 31 10 12 08 Regulation 08 adopted effective January 1 2005 31 23 Md R 1655 January 13 2011 38 1 Md R 12

Uniform Consultation Referral Form

A If a carrier requires a covered person to have a written referral in order to receive services the carrier shall use the uniform consultation referral form as defined in Regulation 02B 6 of this chapter B The carrier may not impose as a condition of coverage a requirement to

Maryland Uniform Consultation Referral Form Date of Referral Patient Information Name Last First MI Date of Birth MM DD YY Phone Member Site Carrier Information Name Maryland Physicians Care MCO Address 1 1201 Winterson Rd 4th Floor Linthicum MD 21090 Phone Number 800 953 8854 Name Last First MI S pecialty

Maryland Uniform Consultation Referral Form Fillable Printable Forms Free Online