Referral Form for HRNW PacifiCare Secure Horizons by wuyunqing

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									                                                 Referring Physicians Portland Family Practice Phone: 503 233 6940             Fax: 503 236-2676
                                                     Susie Bobenrieth MD             Kerry Callahan MD            Rachel Graves MD
                                                     Thomas Kasten MD                Molly Moran-Yandle MD        Elisa Wilson MD
                                                     Josh Reagan MD                  Lauren Roberts MD            Cynthia Shaff-Chin MD
Referral Form for HRNW
PacifiCare / Secure Horizons                     Completed by:_______________________________________ Date:__________
Please submit to HRNW by
                                                 Contact #:__________________________________________
Fax: 503-251-6877
   URGENT             TIME SENSITIVE           ROUTINE       NON-PANEL     (attach notes)   PATIENT REQUEST (attach notes)     RETRO (attach notes)

Member Name:_____________________________________________ ID #:________________________ DOB:__________
               Last                                              First


Referred to:___________________________________________________________________________________________
                      Provider name/Facility                                                                    Specialty
Diagnosis & ICD-9:


Service requested: (Please check and add number of visits requesting)
   Eval              Office Visits ______             Diagnostic Services____________________________________________________

Start of Care Date:                                                                         Facility:_____________________________________

Procedure/CPT:                                                                                  In-Office         Outpatient              Inpatient
Outpatient
Therapy Visits: Physical _____           Occupational _____    Speech _____           Specialty Rehab ___________________________________

Home Health:          RN _____      PT _____     OT ______     HHA ______           MSW _____      ST ______

Infusion Therapy:
DME/HCPC #:
                                                                                                             Last date seen by PCP___________
   Rx for Home Health / Home Infusion / DME / Outpatient Rehab / fax to provider (required).
Adventist Health Home Health & Home Infusion Fax 503 251 6265                                 Adventist Health DME Fax 503 251 6264
Adventist Outpatient Rehab Fax 503 251 6843 ( please note one of the following locations on fax)
                  Main Campus (AMC)            Clackamas             Gresham               Sandy          Vancouver
Notes / Comments:




HRNW use only                        Denied, call me @ ___________________________                  Approved, see below
Auth #:________________________________________ No. of visits auth’d:_____                       Effective dates: from__________ to__________

Auth #:________________________________________ No. of visits auth’d:_____                       Effective dates: from__________ to__________

Auth #:________________________________________ No. of visits auth’d:_____                       Effective dates: from__________ to__________
Procedure authorized:___________________________________________________________________________________________

Processed by / Date:

								
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