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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

 
 
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