Note: This form should only be submitted for the Restricted Recipient Program Members
Member Name:
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Member SCHA ID No.:
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FROM
Referring Provider:
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Tax ID Number:
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Specialty:
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Location:
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Telephone:
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Fax:
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TO
Provider Name:
Tax ID Number:
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Specialty:
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Location:
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Telephone:
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Fax:
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Completed by:
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Contact Phone No.:
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Diagnosis/ICD 9-Code:
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Reason for Referral/Procedure:
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DATES OF SERVICE
From:
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To:
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CONSULTS:
Visits – up to (5) can be authorized.
Consults:
Ancillary Tests (lab, X-ray, etc.)
MRI/Ultrasound/CT/PET Scan
Therapy 9PT/OT/Speech/Sports Medicine
Visits (beyond 20 visit, include clinical information)
Secondary Prescribing Provider?
Option 1
Option 2
Option 3
OUTPATIENT SURGICAL PROCEDURE:
Clinic (Location Code – 11)
Hospital (Location Code – 22)
Surgery Center (Location Code – 24)
Referral Note:
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