Client Information

The information contained in this referral form is privileged and confidential and/or protected health information (PHI) and may be subject to protection under the law, including the Health Insurance Portability and Accountability Act of 1996, as amended (HIPAA). 

This referral form is intended for the sole use of the individual or entity to whom access has been assigned. 

If you are not the intended user, you are notified that any use, dissemination, distribution, printing or copying of this transmission is strictly prohibited and may subject you to criminal or civil penalties. 

If you have reached this form in error, please contact CPHCR and immediately close this refferal form.


 
Client Contact Full Name (Required)
 
 Client Contact Email Address (Required)
  
Case Information
 
 Case Authorization Number (Required)
 
 Turn-around Time (Required)
 
 
 
Type of Service (Required)
 
 Treatment/Medication in Question (Required)
Please include as much information about the treatment/medication in question as possible.
 
 Requesting Reviewer Specialty (Required)
 
 If other was selected, please specify the speciality you are requesting

Member Information
 
 Member Name (Required)
 
Member Mailng Address (Required)
 
 Member Provider Name (Required)
 
  Member Provider Fax Number (Required)
 
 Additional Comments
 
 
Case File Submission
Please include the following:

Application of Independet Medical Review,
Utilization Review Determination including rationale for prior review,
Clinical review criteria and/or medical policy developed and used by health plan,
Terms of Coverage under Covered Person's Health Plan Benefit,
Pertinent Medical Records of Member


***You may submit multiple flies at once****