Santa Barbara Select IPA by MJJKZn

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									CENTINELA VALLEY IPA
     FORMERLY KNOWN AS




                                                         DIRECT REFERRAL FORM
     Fax a copy of this form to Utilization Management. This form is strictly for the use of PCP and Specialist referrals for
       services not requiring authorization. For a list of specialties, please refer to the CVIPA “Quick Reference Guide”

 Patient Name:                                                                      Patient Requested Referral:       Yes     No
                                                                                                                                    Phone:

 Health Plan:                                    Member ID Number:                                              Sex                 DOB:            /            /


                       REFERRED FROM PHYSICIAN                                                              REFERRED TO PHYSICIAN/PROVIDER

Name____________________________________________________                                       Name:_________________________________________________

Phone:_____________________ Fax:_________________________                                      Phone:_____________________ Fax:_______________________

                                                                                               Specialty_______________________________________________

  Was this referral primarily generated at the               Facility Name:
  request of another provider?     Yes     No

  If yes, who? ___________________________
  If yes, Fax # ___________________________                  Admit Date:_________________              If OB, EDC________________

  ICD-9 Code(s):_______________                           Diagnosis:

  Requested Office Visit Code:                                                               Please check appropriate box below if attaching any documents:

                                                                                                   □   Notes                   Total # of pages attached
   Consult Only; CPT Code_________________                                                        □   EKG
                                                                                                   □   Lab
                                                                                                   □   Imaging Results
   Follow Up Visit; CPT Code_______________                                                       □   Consult
                                                                                                   □   Other

  Please print clearly SPECIFIC CLINICAL EXPLANATIONS to support the reason for the request and attach pertinent supporting documentation
  (If Urgent, please include the reason for the urgency):




  PCP Signature: _________________________________________ Date: _______________

NOTE: THIS FORM MAY ONLY BE USED FOR THE SPECIALTY CATEGORIES LISTED BELOW – ALL ENROLLEES:

GASTROENTEROLOGY                                     GENERAL SURGERY (Age 6 & above)
– Coast Gastroenterology                             – HealthNet Senior: Stevan Clark, MD
                                                     – All Other Plans: Robert Shorr, MD; Craig Smith, MD & Ronald Hurst, MD

HEMATOLOGY/ONCOLOGY                                  OPHTHALMOLOGY
– California Hematology/Oncology                     – California Eye Care: Brian Estwick, MD; Veronique Jotterand, MD;
                                                     Sok Nam, MD; Theodore Okie, MD; Joseph Peters, MD & H. Shammas, MD
                                         ALL LAB WORK MUST BE REFERRED TO QUEST DIAGNOSTICS.

LIMITATION OF COVERAGE: Coverage for any authorized request is contingent on eligibility at the time of service as well as the limits
of the benefit plan.
                                                                SUBMIT ENCOUNTER TO:
                                                    CENTINELA VALLEY IPA c/o MEDPOINT MANAGEMENT
                                                        P.O. BOX 571210, TARZANA, CA 91356-9998
                                                      PHONE: (866) 243-8553 x 441 FAX: (866) 243-8564

Copy of Form to be given to patient. PCP to fax authorization to CENTINELA VALLEY IPA MEDICAL GROUP on the same day referral is generated. NOTICE: This form is a
guarantee for payment subject to the following exceptions: CHARGES FOR NON-COVERED SERVICES OR SERVICES RENDERED TO PATIENTS WHOSE COVERAGE IS
NO LONGER IN EFFECT ARE THE PATIENT’S RESPONSIBILITY. Authorization expires in sixty (60) days. Direct Referral Authorization is not valid for providers not
participating on the IPA Panel. ALL FOLLOW-UP CARE MUST BE PRIOR-AUTHORIZED BY THE UTILIZATION REVIEW DEPARTMENT. This protocol applies even when
additional services are provided in conjunction with the initial consultation. Out of network referrals as well as inpatient\outpatient services require pre-certification.
                                                                                                                                                 CVIPA 2010.07

								
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