Referral Instructions

REFERRAL INSTRUCTIONS

-Please check with the office/provider where you are being referred to. Some procedures/visits require (2) separate referrals; (1) for the provider/surgeon and (1) for the facility. If this is your situation, (2) Referrals need to be completed with all information.

-ALL information is required by your insurance company in order to process the referral. (The exception to this is when the receiving office is not able to supply the date of the visit before having the referral approval).

-The information requested on the middle section of the form is obtained from the office you will be going to. Again, this information is required by your insurance company in order to process the referral. Without this we cannot process the form.

-Referral approvals are for a limited time period determined by your health insurance provider. Therefore we process as close to your appointment date to allow the maximum time frame for your referring provider in case they need to reschedule your appointment. If your scheduled appointment is more than 72 hours from the date you submit the referral(s) to us, it will held and processed 72 hours prior to the date of your appointment.

If you are unsure of these instructions please call our office we will be happy to assist you. (215)679-8071. REFERRAL REQUEST FORM 48 business hours notice required

*****All information is necessary to complete referral***** Today’s Date: *______Patient Name: *______Patient Birth Date: *___ /____/_____ Patient Phone: * (___)______Name of your Insurance: *______Member ID #: (located on insurance card)*______

Facility/Specialist being referred to:*______Provider ID Number: (NPI number)*______Specialty: *______Physical address of office*______City: *______Phone Number: *______Fax Number: *______

Diagnosis/Reason: *______Procedure/Test being performed*______Date of Visit or Procedure: *______# of Visits: ______

Valley Medical Center - 2781 Geryville Pike - Pennsburg, PA 18073 Phone (215)679-8071—Fax (215)541-4171

Priscilla J Benner, MD Keith A Bair, PA-C Cathleen M Miller, MSN, CNM

D:\Docs\2018-04-04\0734a238d894146eb6ec96b7cfb9d1b8.docx REFERRAL REQUEST FORM 48 business hours notice required

*****All information is necessary to complete referral***** Today’s Date: *______Patient Name: *______Patient Birth Date: *___ /____/_____ Patient Phone: * (___)______Name of your Insurance: *______Member ID #: (located on insurance card)*______

Facility/Specialist being referred to:*______Provider ID Number: (NPI number)*______Specialty: *______Physical address of office*______City: *______Phone Number: *______Fax Number: *______

Diagnosis/Reason: *______Procedure/Test being performed*______Date of Visit or Procedure: *______# of Visits: ______

Valley Medical Center - 2781 Geryville Pike - Pennsburg, PA 18073 Phone (215)679-8071—Fax (215)541-4171

Priscilla J Benner, MD Keith A Bair, PA-C Cathleen M Miller, MSN, CNM

D:\Docs\2018-04-04\0734a238d894146eb6ec96b7cfb9d1b8.docx