Free Printable Maryland Uniform Consultation Referral Form Submit the completed Uniform Consultation Referral Form to CareFirst BlueChoice applies to PCP only by fax to 410 505 6160 or 1 800 354 8205 Forms can also be mailed to Mail Administrator P O Box 14116 Lexington KY 40512 4116 This is not the correct form to refer a member for laboratory or radiology services
Primary or Requesting Provider Consultant Facility Provider Referral Information Referral certification is not a guarantee of payment Payment of benefits is subject to a member s eligibility on the date that the service is rendered and to any other contractual provisions of the plan carrier Maryland Uniform Consultation Referral Form Date of Referral Patient Information Name Last First MI Date of Birth MM DD YY Phone Member Site Carrier Information Name Maryland Physicians Care MCO Address 1 1201 Winterson Rd 4th Floor Linthicum MD 21090 Phone Number 800 953 8854 Name Last First MI S pecialty
Free Printable Maryland Uniform Consultation Referral Form
Free Printable Maryland Uniform Consultation Referral Form
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Maryland Uniform Consultation Referral Form Carrier Information Patient Information Date of Referral Name Last First MI 410 767 0261 or toll free 1 800 535 0182 Physician s The Maryland Infants and Toddlers Program Guide For Referring Children with Developmental Delays and print name of parent or guardian give my Refer a Patient to a Specialist Primary care providers must use the Maryland Uniform Consultation Referral Form PDF when referring MedStar Family Choice members to Specialists The forms are valid for 180 days Complete the referral form in its entirety and the authorizing signature box must be signed by the PCP
The Maryland Uniform Dental Consultation Referral Form shall read as follows Click here to view Image B The electronic equivalent of the uniform consultation referral form is as follows Uniform Dental Consultation Referral Field Length Start Stop 1 Patient last name 18 1 18 2 Patient first name 12 19 30 Referral Information Referral certification is not a guarantee of payment Payment of benefits is subject to a member s eligibility on the date that the service is rendered and to any other contractual provisions of the plan carrier White Carrier Yellow Primary or Requesting Provider Pink Consultant Facility Provider Goldenrod Patient
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31 10 12 06 Ma land Uniform Consultation Referral Form Date of Referral Patient Information Carrier Information Name Address Phone Number Facsimile Data or Requestin Provider Specialty Provider ID 1 Facsimile Data Number Provider ID 2 If Required Provider ID 2 If Required Name Last First Maryland Code of Regulations Title 31 MARYLAND INSURANCE ADMINISTRATION Subtitle 10 HEALTH INSURANCE GENERAL Chapter 31 10 12 Uniform Consultation Referral the carrier shall use the uniform consultation referral form as defined in Regulation 02B 6 of this chapter B
Health Care Providers Certain uniform forms are required by the state of Maryland to be used by health care providers when submitting to insurance carriers This section provides the requirements instructions and the forms Uniform Credentialing Uniform Credentialing Form Bulletin October 7 2009 Life and Health 09 25 CAQH Credentialing Form Primary or Requesting Provider Consultant Facility Provider Referral Information Referral certification is not a guarantee of payment Payment of benefits is subject to a member s eligibility on the date that the service is rendered and to any other contractual provisions of the plan carrier
Maryland Uniform Consultation Referral Form Fill Out And Sign Printable PDF Template SignNow
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https://provider.carefirst.com/carefirst-resources/provider/pdf/uniform-consultation-referral-form-unt0001.pdf
Submit the completed Uniform Consultation Referral Form to CareFirst BlueChoice applies to PCP only by fax to 410 505 6160 or 1 800 354 8205 Forms can also be mailed to Mail Administrator P O Box 14116 Lexington KY 40512 4116 This is not the correct form to refer a member for laboratory or radiology services
https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/community-providers/mas/ever/uniform-consultation-referral-form-en.pdf
Primary or Requesting Provider Consultant Facility Provider Referral Information Referral certification is not a guarantee of payment Payment of benefits is subject to a member s eligibility on the date that the service is rendered and to any other contractual provisions of the plan carrier
Printable Blank Referral Form
Maryland Uniform Consultation Referral Form Fill Out And Sign Printable PDF Template SignNow
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Free Printable Maryland Uniform Consultation Referral Form Printable Forms Free Online
Free Printable Maryland Uniform Consultation Referral Form Printable Forms Free Online
Free Printable Maryland Uniform Consultation Referral Form Printable Forms Free Online
Maryland Uniform Consultation Referral Form Fillable Printable Forms Free Online
Printable Medical Referral Form Template
Free Printable Maryland Uniform Consultation Referral Form - Refer a Patient to a Specialist Primary care providers must use the Maryland Uniform Consultation Referral Form PDF when referring MedStar Family Choice members to Specialists The forms are valid for 180 days Complete the referral form in its entirety and the authorizing signature box must be signed by the PCP
