ࡱ>  bjbj ~eek!  z(z(z(z(z(4(((h)Tj*(^T^+p////4.5#5ASCSCSCSCSCSCS$DWYgSz(354@43535gSz(z(//TAAA35z(/z(/RA35ASAA6oKL/G8OLR.T0^TkLZ:@Z8LLZz(M3535A3535353535gSgS>j353535^T35353535Z353535353535353535  @':   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: Complete the Referral to Specialist Form. 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. 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  FORMTEXT      First  FORMTEXT      Middle initial  FORMTEXT  Suffix  FORMTEXT      Gender M  FORMCHECKBOX  F  FORMCHECKBOX Member ID number (From the member ID card. For example: AMK 100000000 01) AMK  FORMTEXT        FORMTEXT   Date of birth  FORMTEXT      Member home address (no P.O. Box)  FORMTEXT      Member telephone number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     Member email address (optional)  FORMTEXT      Providers: To submit a referral to an in-network specialist, complete and submit this form. Instructions on reverse. Section 1: Treatment information for memberA. Referral start date (Do not date retroactively)  FORMTEXT      B. Referral end date (If not dated, referral ends after one year)  FORMTEXT      C. Standing referral request? Yes  FORMCHECKBOX  No  FORMCHECKBOX  (requires approval)Section 2: Referring Primary Care Provider informationA. Primary care provider (PCP) Name: Last  FORMTEXT      First  FORMTEXT      Middle initial  FORMTEXT  Suffix  FORMTEXT      B. PCP Tax ID number or Social Security number* (mandatory)  FORMTEXT     -  FORMTEXT    -  FORMTEXT     C. PCP NPI number (optional)  FORMTEXT      D. PCP service location address (no P.O. Box)  FORMTEXT      E. PCP billing address  FORMTEXT      F. PCP telephone number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     G. Email address (optional)  FORMTEXT      Covering provider information (to be filled out when a provider covering for the PCP makes a referral)H. Covering provider name: Last  FORMTEXT      First  FORMTEXT      Middle initial  FORMTEXT  Suffix  FORMTEXT      I. Covering provider Tax ID number or Social Security number* (mandatory)  FORMTEXT     -  FORMTEXT    -  FORMTEXT     J. Covering provider NPI number (optional)  FORMTEXT      K. Covering provider telephone number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     L. Covering provider email address (optional)  FORMTEXT      Section 3: Specialist informationA. Specialist name: Last  FORMTEXT      First  FORMTEXT      Middle initial  FORMTEXT  Suffix  FORMTEXT      B. Specialist Tax ID number or Social Security number* (mandatory)  FORMTEXT     -  FORMTEXT    -  FORMTEXT     C. Specialist NPI number (optional)  FORMTEXT      D. Specialist location address (no P.O. Box)  FORMTEXT      E. Specialist billing address  FORMTEXT      F. Specialist telephone number ( FORMTEXT    )  FORMTEXT     -  FORMTEXT     G. Specialist email address (optional)  FORMTEXT      Section 4: Signature of referring providerI 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 XSignature date  FORMTEXT      * 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 ha  .345BJKQghijrsjaRBhRhB5OJQJ^JaJh9h7+OJQJ^JaJh7+h*ZCJh+3h82CJhhB5CJ ^JaJ hh7+5CJ ^JaJ hh825CJ ^JaJ hoCJ ^JaJ hh82CJ ^JaJ hRCJ h*ZCJhfh*ZCJaJhfhf5CJaJhfhT5CJaJ hT5CJjhTUmHnHu h5CJhijB C [  xgd7+xgdR & F gdR & F Pgd xxgdRxxgd2F dxxgdRPgd  P Hgd+3P P$ 6$a$gdTrst{  " , - . 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