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How do I fill this out?
To fill out the referral form, begin by providing your personal details in the designated fields. Next, specify the type of service you are requesting and provide any necessary clinical justification. Finally, ensure all required signatures are obtained before submission.
How to fill out the Referral Form for OB/GYN Services?
1
Read through the form to understand the requirements.
2
Fill in the personal and clinical information as requested.
3
Select the necessary service and provide a justification.
4
Ensure all sections are completed accurately.
5
Submit the form to the appropriate provider.
Who needs the Referral Form for OB/GYN Services?
1
Pregnant individuals seeking consultations.
2
Women needing routine well-woman exams.
3
Patients requiring specific OB/GYN in-office procedures.
4
Individuals requesting tubal ligation services.
5
Members needing total OB care from network specialists.
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1
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What are the instructions for submitting this form?
To submit this form, fax it to (909) 890-5751 for general referrals and to (909) 890-5763 for behavioral health referrals. Ensure that all sections are filled out properly and signed as required. If you prefer, you can also consult with your provider about electronic submission options.
What are the important dates for this form in 2024 and 2025?
Important dates for the referral process in 2024 and 2025 will be provided in updates. Keep up-to-date with any changes that may occur regarding service offerings and deadlines. Always check the provider's announcements for the latest information.
What is the purpose of this form?
The purpose of this form is to facilitate referrals for OB/GYN services required by IEHP members. It ensures that the necessary approvals are obtained for medical services without delay. Additionally, it serves as a record for both the member and the healthcare provider regarding the services requested.
Tell me about this form and its components and fields line-by-line.
- 1. Member Name: Name of the member requesting the referral.
- 2. Plan: Specify the applicable health insurance plan.
- 3. Diagnosis: Required medical diagnosis to justify the referral.
- 4. ICD-10 Code: Required code corresponding to the diagnosis.
- 5. Referring Provider Signature: Signature of the provider making the referral.
What happens if I fail to submit this form?
Failure to submit this form may result in delays in accessing necessary OB/GYN services. It is crucial to ensure that all necessary fields are completed and the form is submitted on time. Without proper submission, a member may face difficulties in receiving care.
- Delayed Care: Patients may experience delays in receiving required medical attention.
- Ineligible Services: Services may be deemed ineligible if the referral is not properly completed.
- Increased Administrative Task: Providers may have to deal with additional paperwork if submissions are incomplete.
How do I know when to use this form?
- 1. Consultations: For initial or follow-up consultations with OB/GYN specialists.
- 2. Routine Exams: For scheduling well-woman exams as part of preventive care.
- 3. In-Office Procedures: To request necessary in-office procedures that require a referral.
- 4. Surgery Requests: For submitting requests for surgical procedures, such as tubal ligation.
- 5. Total OB Care: For members seeking comprehensive obstetrical care and delivery services.
Frequently Asked Questions
How do I fill out the referral form?
You need to provide your personal details, specify the service, and obtain necessary signatures.
Can I edit this PDF?
Yes, you can edit the PDF using the PrintFriendly editing feature before submission.
Is there a deadline for submission?
It's best to submit your referral as soon as possible to ensure timely processing.
What if I make a mistake on the form?
You can use the editing feature to correct errors prior to submission.
How do I submit the completed form?
You can submit via fax to the number provided, or share electronically if needed.
Who should I contact for help?
For assistance, call the number listed on the form.
Are there any required documents?
Yes, you may need to attach clinical justification documents.
Can I save this form?
You can download the completed form after filling it.
What if my request is denied?
You'll receive a notification, and you can contact the relevant number for further assistance.
What types of services can I request?
You can request consultations, well-woman exams, and more OB/GYN services.
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