Transcription of Phone (800) 874 -2091 DATE SUBMITTED:
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Phone (800) 874 -2091 DATE SUBMITTED:
Fax authorization request to: (800) 874-2093 Phone (800) 874 -2091 REFERRAL / AUTHORIZATION REQUEST Check one health plan below : Select membership type: Blue Cross Citizens Choice Care Medi-Cal Blue Shield Easy Choice Humana Healthy Kids Brand New Day health Net Molina Medicare or Cal MediConnect Care 1st Covered California MARK HERE FOR TYPE OF REQUEST: URGENT ROUT INE RET ROA C T I V E INPA T IENT Patient Name LAST FIRST MA L E FEMA L E DOB A GE Address City Zip Phone Member Number Language Required (Interpreter Services Available) PATIENT REFERRED TO: Address: Specialty: Phone #: FAX #: REFERRING PHYSICIAN: Referring Physician Address Referring Phone : Referring Fax: Referring Signature (REQUIRED) Diagnosis Codes (ICD9): Diagnosis Description: ICD9 Code 1: ICD9 Code 2: IMPO RTANT NO TIC E REGARDING Q UES T an d LAB C O RP - LABS MUST BE SENT T O T HE ASSIGNED CONT RACT ED LAB FOR T HE MEMBER S PCP.
Fax authorization request to: (800) 874-2093 Phone (800) 874 -2091 REFERRAL / AUTHORIZATION REQUEST . Check one health plan below: Select membership type:
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