1. No category

Lock-In Non-Designated Provider
Referral Form
Phone: 1-888-470-0550 Opt 8
Fax: 1-866-415-2818
Lock-in PCP/Referring Provider:
PLEASE NOTE THIS REFERRAL IS ONLY FOR A LOCK IN MEMBER
ALL ITEMS WITH AN * MUST BE COMPLETED OR THE FORM WILL BE RETURNED
*Name:
*Date of Referral:
*NPI #:
*Provider TIN #:
Provider ID #:
Contact Name:
Fax Number:
Phone Number:
*Provider Being Referred To:
*Name:
*Provider Address:
Contact Name:
Provider ID #:
*Provider TIN #:
*NPI #:
Member Information:
*CoventryCares
Member ID #:
Member Name:
*Diagnosis and
Code:
CPT Code:
ICD9 Code:
*Reason for
Referral:
*Type of Referral: □ Consult
□ Consult and Treat
* If Consult and Treat, length of treatment:
□ 1 month □ 3 months □ 6 months □ 9 months □ 12 months
** # of visits requested:
Plan Use Only
Referral #:
To Date:
Length of treatment approved:
□ 1 month
□ 3 months
□ 6 months
# of visits approved:
______________________________
Signature of Referring Lock-In PCP
From Date:
□ 9 months
□ 12 months
_____________________
Date
KYCM00183