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Helpful Hints for the Passport Health Plan Referral Form

The Passport Health Plan Referral Form must be completed by the primary care provider (PCP) and distributed to the appropriate parties. The Plan must receive the correct copy in order for payment to be made to specialists.

Completing the Form

All fields on the form must be completed. Here is a quick reference guide:

Top of Form
Please include all requested member information.

"Please Note" Box
Contains important information regarding the referral process. Read this section carefully!

"Referred to" Section
Please include all requested information regarding the specialist, the diagnosis, and ICD-9 code.

Reasons for Referral
Below "PCP Must Check One of the Following" is a list of reasons for the referral. Remember to check only one!

Authorizing Signature
Don't forget to sign and date the form!

Distributing the Form

Here is a quick reference guide for the appropriate distribution channels:

White Copy
Send to:
Passport Health Plan
P. O. Box 7114
London, KY 40742

Yellow Copy
Keep for member's chart/PCP records

Pink Copy
Give to member

Gold Copy
Send to specialist