| 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
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| All fields on the form must be completed.
Here is a quick reference guide: |
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| Top of Form |
Please include all requested member information.
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| "Please Note" Box |
Contains important information
regarding the referral process. Read this section carefully! |
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| "Referred to" Section |
Please include all requested
information regarding the specialist, the diagnosis, and
ICD-9 code. |
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| Reasons for Referral |
Below "PCP Must Check One
of the Following" is a list of reasons for the referral.
Remember to check only one! |
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| Authorizing Signature |
Don't forget to sign and date
the form! |
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Distributing the Form
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| Here is a quick reference guide for the appropriate
distribution channels: |
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| White Copy |
Send to:
Passport Health Plan
P. O. Box 7114
London, KY 40742
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| Yellow Copy |
Keep for member's chart/PCP records |
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| Pink Copy |
Give to member |
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| Gold Copy |
Send to specialist |
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