Provider In-Network Only Specialist Referral Form Amazon



Amazon and Subsidiaries

In-Network Only Plan

Primary Care Provider (PCP) Referral to Specialist

Provider: If you are using this referral form, it means you have been selected by this member

to be their Primary Care Provider for their medical plan. The member will look to you to coordinate

their medical care.

Provider Instructions:

1. Complete the Referral to Specialist Form.

2. Fax the completed form to Premera Blue Cross, Attn: Customer Service, at 888-617-0495. You must submit the form before an in-network specialist provides services to the member. Premera will deny plan benefits to the member if the services are delivered before Premera receives the completed form.

3. Give the member a copy of the completed Referral to Specialist Form for their records.

If no end date is specified in Section 1-B of the form, then this referral remains in effect for one year after the start date in Section 1-A. Standing referrals (no end date specified) require approval from Premera.

A referral form is not required for standard services in the obstetric, chiropractic, and gynecologic specialties. The member does not need approval in advance for treatment of life-threatening conditions or urgent and emergency care.

Receipt and acceptance of this referral form does not guarantee a benefit nor does it constitute a benefit advisory. To find out if there is a benefit advisory on file for this member or to find out the status of a referral, call Premera Customer Service at 877-995-2696.

Primary Care Provider (PCP) Referral to Specialist

In-Network Only Plan

Member: When you need a referral to an in-network specialist, fill out the information below and then take this form

to your provider to complete.

|Member name: Last |First |Middle initial |Suffix |Gender |

|      |      |  |      |M F |

|Member ID number (From the member ID card. For example: AMK 100000000 01) |Date of birth |

|AMK          |      |

|Member home address (no P.O. Box) |

|      |

|Member telephone number |Member email address (optional) |

|(   )     -      |      |

Providers: To submit a referral to an in-network specialist, complete and submit this form. Instructions on reverse.

|Section 1: Treatment information for member |

|A. Referral start date (Do not |B. Referral end date (If not dated, referral |C. Standing referral request? |

|date retroactively)       |ends after one year)       |Yes No (requires approval) |

|Section 2: Referring Primary Care Provider information |

|A. Primary care provider (PCP) Name: Last |First |Middle initial |Suffix |

|      |      |  |      |

|B. PCP Tax ID number or Social Security number* (mandatory) |C. PCP NPI number (optional) |

|    -    -      |      |

|D. PCP service location address (no P.O. Box) |

|      |

|E. PCP billing address |

|      |

|F. PCP telephone number |G. Email address (optional) |

|(   )     -      |      |

|Covering provider information (to be filled out when a provider covering for the PCP makes a referral) |

|H. Covering provider name: Last |First |Middle initial |Suffix |

|      |      |  |      |

|I. Covering provider Tax ID number or Social Security number* (mandatory) |J. Covering provider NPI number (optional) |

|    -    -      |      |

|K. Covering provider telephone number |L. Covering provider email address (optional) |

|(   )     -      |      |

|Section 3: Specialist information |

|A. Specialist name: Last |First |Middle initial |Suffix |

|      |      |  |      |

|B. Specialist Tax ID number or Social Security number* (mandatory) |C. Specialist NPI number (optional) |

|    -    -      |      |

|D. Specialist location address (no P.O. Box) |

|          |

|E. Specialist billing address |

|          |

|F. Specialist telephone number |G. Specialist email address (optional) |

|(   )     -      |           |

|Section 4: Signature of referring provider |

|I certify that all information I have provided in this application, including any attachments, is accurate and complete to the best of my knowledge. I |

|understand that any false statement or misrepresentation of the information I have provided on my referral request or attachments will be grounds for |

|rejection of claims arising from this referral. I also understand that receipt and acceptance of this referral form does not in any way indicate that any |

|services provided subsequent to this referral are assured of benefits coverage under this plan. Coverage of services information and confirmation of benefits|

|must be sought through the other normal channels available. (Call Premera Customer Service at 877-995-2696.) |

|Referring provider signature |Signature date |

|X |      |

* Either TIN or SSN may be provided. However, billing statements must use the TIN or SSN provided on this form.

Fax completed form with any needed attachments to Premera Blue Cross: 888-617-0495.

If you are using this referral form, it means you have been selected by this member to be

their Primary Care Provider for their medical plan. The member will look to you to coordinate their medical care.

Detailed form instructions for providers

Section 1:

PCP provides information about member who will see specialist.

A. Date when referral is effective; specialist may start to provide services to this member on this date. Retroactive dates will be denied.

B. Date when referral to the specialist ends. If this field is left blank the referral will default to one year after the start date.

C. Yes or no: Do you want a standing referral for this specialist? This requires approval. Contact Customer Service for more information.

Section 2:

PCP or provider covering for PCP supplies provider information.

A. Last name, first name, middle initial, and suffix (if one applies) of PCP. If a covering provider is making this referral, supply this information for the PCP.

B. Either tax identification number or social security number of PCP. (Mandatory)

C. National Provider Identification (NPI) number of PCP, if number exists. If this number is provided, claims will process more quickly. (Optional)

D. Physical address of PCP service location. No P.O. Box numbers in this field.

E. Address where PCP wants to get billing information. P.O. Box numbers OK.

F. Telephone number for PCP.

G. Email address for PCP. (Optional)

H. Last name, first name, middle initial, and suffix (if one applies) of provider covering for PCP.

I. Either tax identification number or Social Security number of covering provider.

J. National Provider Identification (NPI) number of covering provider, if number exists. If this number is provided, claims will process more quickly. (Optional)

K. Telephone number for covering provider.

L. Email address for covering provider. (Optional)

Section 3:

PCP or covering provider supplies information about the specialist.

A. Last name, first name, middle initial, and suffix (if one applies) of referred specialist provider.

B. Either tax identification number or

Social Security number of referred specialist provider. (Mandatory)

C. National Provider Identification (NPI) number of referred specialist provider, if number exists. If this number is provided, claims will process more quickly. (Optional)

D. Physical address of referred specialist provider service location. No P.O. Box numbers in this field.

E. Billing address of referred specialist provider.

F. Telephone number of referred specialist provider.

G. Email address of referred specialist provider. (Optional)

Section 4:

PCP or covering provider must read, sign, and date this section, then fax signed form to number at bottom of form.

Fax the completed form, along with any attachments needed to support the referral, to Premera Blue Cross at 888-617-0495. If you have any questions, call Premera Customer Service at 877-995-2696.

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