0 Medi-Cal Managed Care (SFHP: San Francisco Health Plan)

REFERRAL AUTHORIZATION FORM Medi-Cal Managed Care (SFHP: SF Health Plan) Other: NEMS-MSO – 369 Broadway Street, San Francisco, CA 94133 – Tel: (415) 352-5045 Fax: (415) 398- 2895 Member Information Name: Date of Birth: SFHP ID #: PCP/Referring Provider Name: Phone #: Fax #:

Name: Specialty:

Specialist Contact Person: Phone #: Ext.:

Address: Fax #:

CLINICAL INFORMATION Problem / Diagnosis: ICD-9: This referral is valid for: One (1) Visit For Consultation Second Opinion Two (2) Visits Follow-up Reason for Referral: (attach related medical reports as necessary)

This referral is valid for up to six (6) months from the PCP Requesting: Signed: Date: date signed by PCP. The above area is for PCP/Referring Provider use only. Important Note: Services which have not received an Authorization Number will not be paid. Payment is contingent upon eligibility at the time of service. Providers are responsible for checking patient eligibility prior to rendering services. To verify eligibility, call SFHP directly at (415) 547- 7810. SPECIALIST REPORT

Specialist Signature: Date: For NEMS-MSO Use Only: Auth #:

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