Referral/prior Authorization Request Form - Primary Health
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1REFERRAL/PRIOR
AUTHORIZATION REQUEST FORM
Fax completed form to
(541) 956-5460
Phone (541) 471-4208
Toll Free (800) 471-0304
REQUESTING PROVIDER
– COMPLETE THIS SECTION:
LAST
FIRST
MI
Patient Name
DMAP ID#
DOB
Primary Care Provider
Contact Person
Requesting Clinic/Provider
Clinic Phone #
Clinic Fax #
Referred To: (Provider)
Referred To: (Facility, if di erent)
Services Requested
Check if
nd opinion
2
Providers Phone #
Providers Fax #
Appt/Procedure Date
Referral Start Date
Number of Visits Requested (Check One)
*Preferred for
OTHER ___________________
2 VISITS
3 VISITS
6 VISITS
In
Months
In
Months
Initial Requests*
3
6
ICD
DX Codes *
1
)________________
2
)________________
3
)________________
4
)________________
5
)________________
10
**Requesting provider, please submit ICD -
Dx codes. Include Primary, Secondary, and Related/Comorbid Dx Codes.
10
Surgery/Procedure/Injectable Medication/Equipment
INSTRUCTIONS: Please list CPT (procedure code(s)) or HCPC codes requested and indicate corresponding diagnosis code number from list above.
CPT/HCPC
Corresponding Diagnosis
Quantity
Description/Notes
Code
POINT TO CORRESPONDING DX: EX
1, 3,
ETC
___________________________________________
________________________
Requesting Provider’s Signature:
Date:
**ATTENTION PROVIDER**
Referrals are not valid until eligibility, bene ts and diagnosis have been veri ed and referral number is assigned by PrimaryHealth.
Guidelines may apply to surgery, some diagnostics and some injections. Retroactive referrals will be considered up to
days following the
30
date of service.
Please note OHP guidelines allow up to
days to approve or deny this request. You will be noti ed of our decision.
Please allow at least
14
5
business days for processing prior to calling the o ce to inquire about the status of this request. Please send relevant chart notes to expedite
processing. If your request is medically urgent, please print a note on this form to alert us to your processing needs. Thank You.
PrimaryHealth of Josephine County
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