Free Empire Referral Form in PDF

Instructions on Writing Empire Referral

Upon deciding to submit an Empire Referral form, individuals engage with a process crucial for the continuity of their healthcare journey, particularly when services outside their primary provider are necessary. The accurate completion of this form enables patients to access specialist care or specific treatments that require pre-approval. It's a straightforward process, yet attention to detail is paramount to ensure the request proceeds without hindrance. Once completed and submitted, the form undergoes review by Empire's medical management team. The approval process considers the necessity and appropriateness of the requested service against the patient's health plan benefits. Keeping in mind the stipulated exclusions, like services from non-participating providers or certain types of admissions which require direct contact with Empire Medical Management, is crucial.

1. Gather all necessary patient information, including the Policyholder's name and the patient's ID number, last name, first name, middle initial (MI), and date of birth (MM/DD/YYYY).
2. Fill in Section 1, ensuring to input all required fields marked with an asterisk (*). These include the Patient ID No., Last Name, First Name, MI, and Date of Birth.
3. In Section 2, provide the referring physician's information. Include the provider's last name, first name, MI, service address, Empire provider ID or NPI, and phone number.
4. Identify the specialist or service provider to whom the referral is made in Section 3. Input the Specialist's Last Name, First Name, MI, Service Address, Empire Provider ID or NPI, and Phone No.
5. Complete Section 4 with authorization information which is critical for service approval. Indicate the Number of Visits, Service Start Date, and Service End Date. Detailed reasons for referral, any remarks or limitations, should be noted to clarify the necessity of the referral.
6. The referring physician must sign and date the form in the spaces provided at the end of Section 4, marking the consent and validation of information provided.
7. Double-check the form to ensure all required fields are completed and that no critical information is missing or inaccurately provided.
8. Fax the completed form to 1-800-522-5793, ensuring that a confirmation of the sent fax is received, to verify the document has reached its destination.
9. Keep a copy of the fax confirmation alongside a photocopy of the completed form for personal records and future reference.

After submission, patience is essential as the review process takes time. Should there be any inquiries or a need for further clarification regarding the referral form or its status, contacting Empire Medical Management directly is advised. This proactive approach ensures that any potential issues can be addressed promptly, facilitating a smoother pathway to accessing the requisite care.

What is the purpose of the Empire Referral Form?

The Empire Referral Form is designed to facilitate the process of obtaining approval for specific healthcare services under Empire Health Plans. These plans include HMO, Child Health Plus, Healthy NY, Direct Pay HMO, and Direct Pay HMO/POS. The form is a way for a primary care physician (PCP) to refer a patient to a specialist or for specific treatments that require pre-approval, ensuring that the patient receives covered care within the Empire network.

Which services cannot be approved using the Empire Referral Form?

Certain services require direct contact with Empire Medical Management for approval and are not covered under the standard referral process. These services include care from non-participating providers, inpatient hospital admissions, emergency and maternity admissions, home care services including hospice and private duty nursing, Empire Baby Care, and surgeries not performed in a doctor's office. For approval of these specific services, individuals should contact Empire Medical Management directly.

How long is the referral valid?

Once issued, referrals are valid for a duration of 90 days from the service start date, unless the referring physician specifies otherwise on the form. It's important for patients and healthcare providers to be aware of this timeline to ensure that all care is received within the validity period of the referral. Also, it's crucial to understand that any authorized services are subject to the limitations and exclusions outlined in the patient's contract with Empire HealthChoice.

What happens if a required field on the form is not completed?

The referral form includes several fields that are marked as required. These fields must be completed for the referral to be processed and accepted by Empire HealthChoice. Missing information in any of these required fields will result in the referral not being accepted, potentially delaying the patient's access to necessary specialist care or treatment. It's essential for healthcare providers to carefully review the form before submission to ensure all required information is provided.

When filling out the Empire Referral form, it's crucial to pay attention to details to ensure that your request is processed smoothly. One common mistake is neglecting to include the Patient ID number. This crucial piece of information helps to accurately identify the patient within the system, and omitting it can lead to delays or the referral not being accepted.

Another oversight occurs in the patient information section, specifically with the date of birth. Some people mistakenly enter the current date or an incorrect format, which can cause confusion and incorrect processing of the form. It's important to follow the MM/DD/YYYY format to avoid any issues.

Not filling in the required fields is a significant error that can cause a referral to be refused. The form marks certain fields as mandatory, indicated by an asterisk (*). Ignoring these prompts and leaving required fields empty will result in the form being incomplete, thereby delaying the patient's care.

In Section 2, which focuses on the referring physician information, a common mistake is not providing the Empire provider ID or NPI. This identifier is essential for verifying the physician within the Empire system. Without it, the referral cannot be correctly attributed and might be rendered invalid.

When specifying referral to information, it's critical to double-check the accuracy of the specialist's last name, first name, and ID numbers. Misspellings or incorrect IDs can direct the referral to the wrong provider, potentially causing a delay in the patient receiving the necessary care.

Overlooking the authorization information section, especially the services' start and end dates, limits the validity of the referral. These dates inform Empire of the timeframe for the authorized services, an essential element for scheduling and coverage purposes. Failure to include precise dates can result in administrative hurdles and delays in service provision.

Another mistake is failing to clearly state the reason for the referral or including remarks/limitations. This information guides the specialist and the Empire team, ensuring that the referral is appropriate and meets the patient's needs. Vague or missing details can lead to misinterpretation and affect the quality of care.

Sometimes individuals forget to obtain the signature of the referring physician. This endorsement is a critical step in the referral process, serving as a professional validation of the need for specialized services. Without the physician's signature, the form is incomplete and cannot be processed.

Finally, neglecting to provide updated contact information, including the fax number and the web address printed on the form, can hinder communication. Ensuring that the Empire team can reach you for any clarifications or updates facilitates a smoother, more efficient referral process.

In the realm of healthcare, numerous forms and documents work in tandem with the Empire Referral Form to ensure a seamless process for managing patient care. These documents support various stages of medical treatment, from initial referrals to post-treatment care, and play a pivotal role in the coordination between healthcare providers, insurance entities, and patients themselves. The list below provides an overview of other essential forms and documents often used alongside the Empire Referral Form.

• Prior Authorization Form: This document is necessary for obtaining pre-approval from an insurance provider for specific services or medications, ensuring that the treatment is covered under the patient's health plan.
• Appointment Scheduling Form: Used by medical offices to organize and confirm appointments with specialists or for specific procedures, detailing the time, date, and nature of the visit.
• Medical Records Release Form: Allows the sharing of a patient’s medical history and records between healthcare providers, ensuring the receiving party has comprehensive background information for informed care decisions.
• Health Insurance Claim Form: Submitted to insurance companies for the reimbursement of healthcare services provided, outlining the details of the treatment, the provider, and the cost.
• Patient Intake Form: Collected by the specialist or healthcare facility prior to the first visit, gathering detailed information about the patient's medical history, current medications, and the reason for the visit.
• Privacy Notice Acknowledgment Form: Confirms that a patient has received and understands how their personal health information may be used and disclosed under HIPAA regulations.
• Treatment Plan Form: Developed after the initial consultation with the specialist, this outlines the recommended course of treatment, planned procedures, and expected outcomes for the patient.
• Medication Management Form: Used to track prescribed medications, dosages, and schedules, ensuring proper adherence and monitoring of potential side effects or interactions.
• Discharge Summary Form: Prepared upon a patient's discharge from hospital care or after completing a treatment phase, summarizing the care received, outcomes, and any follow-up instructions or medications prescribed.

Together, these documents form a comprehensive network of information exchange and coordination necessary for efficient and effective patient care management. They facilitate smooth transitions between care providers, support accurate and timely billing, and ensure that patients receive the necessary services in accordance with their health plans. Understanding the function and importance of each form can significantly enhance the healthcare journey for patients, providers, and insurers alike.

The Empire Referral Form shares similarities with a Prior Authorization Form utilized within the healthcare industry. Both forms serve as gatekeepers for specific healthcare services, requiring prior approval from an insurance company before the service is rendered. The inherent aim is to verify the necessity and appropriateness of the requested service, ensuring it aligns with the patient's health plan benefits. Each form mandates detailed information about the patient, the provider requesting the service, and specifics about the service itself, fostering a streamlined communication channel between healthcare providers and insurance entities.

Similar to a Prescription Order Form that doctors use to prescribe medication, the Empire Referral Form necessitates a physician's input to initiate a specialized healthcare service. Both documents are critical in guiding the next steps in a patient's care, emphasizing the doctor's role in specifying the required medical service or medication. The referral form extends this pathway by linking the patient with a specialist or specific service, whereas the prescription order directly enables the patient to access medications.

An Insurance Claim Form is yet another document sharing functional parallels with the Empire Referral Form. Both types of forms are integral to the healthcare billing process, facilitating financial transactions related to patient care. While the Insurance Claim Form is primarily used for billing purposes after services have been provided, the referral form acts preemptively, ensuring the service is approved for coverage under the patient's health insurance plan prior to being undertaken.

The Medical Records Release Form, like the Empire Referral Form, demands detailed patient information and the healthcare provider's authorization. However, the former is principally engaged in the sharing of a patient’s health history between medical entities, possibly to support the continuation of care that begins with a referral. This connection underscores the importance of seamless information flow in patient care, whether for initiating specialized services or for consolidating patient health records.

Appointment Request Forms found in many healthcare settings share a common goal with the Empire Referral Form: to schedule healthcare services. While the Appointment Request Form is a more general application for any type of visit, the referral form is a specialized version that not only schedules but also secures authorization for specific services with a specialist or within specialized facilities, underlining the structured pathway to specialized care necessitated by some health insurance plans.

Healthcare Consent Forms, which are used to obtain a patient's agreement before undergoing any medical procedure or treatment, share the foundational need for clear communication and authorization seen in the Empire Referral Form. Each document ensures that involved parties are informed and in agreement over the healthcare services to be provided. However, consent forms specifically capture the patient's understanding and acceptance of the risks associated with a procedure, emphasizing patient autonomy in care decisions.

The Patient Intake Forms, commonly filled out on a first visit to a new healthcare provider, collect comprehensive patient information, mirroring the section of the Empire Referral Form dedicated to patient details. This similarity highlights the universal need in healthcare to understand a patient's background, insurance coverage, and medical history as a basis for providing care, whether it be routine, specialized, or emergency in nature.

The Transfer of Care Form, used when a patient is being referred from one healthcare provider to another, shares a direct purpose with the Empire Referral Form in facilitating a patient's transition between care settings or specialties. Both documents coordinate the passage of care responsibility, ensuring the receiving provider has the necessary information and authorization to proceed with the recommended services, underlining the collaborative nature of patient-centered care.

A Treatment Plan Form, designed to outline a proposed healthcare strategy for a patient, has parallels with the Empire Referral Form in its forward-looking approach to patient care. While the Treatment Plan Form outlines the broader strategy for addressing a patient's health concerns, including goals and timelines, the referral form can be seen as actioning a specific part of this plan by connecting patients with specialized services that fit within their broader treatment objectives.

When filling out the Empire Referral Form, it's crucial to ensure accuracy and completeness to facilitate a smooth referral process. Here are some guidelines to help:

• Verify the details: Double-check that all information entered on the form is accurate, including patient details, referring physician information, and specialist information.
• Include all required fields: Make sure to complete every section marked as required. This includes patient ID number, patient and policyholder names, date of birth, provider, and specialist details, among others.
• Use the correct form version: Ensure you are using the most current version of the form to avoid any processing delays due to outdated information or formats.
• Contact Empire Medical Management for exceptions: For services that are not covered under the standard referral process, such as non-participating provider services or inpatient admissions, directly contact Empire Medical Management as instructed.
• Clarify referral duration: Clearly indicate the start and end dates for the service, remembering that referrals are usually valid for 90 days unless otherwise specified.

• Leave optional/not required fields blank if relevant: While certain fields like the PCP’s Tracking number are optional, filling them out when applicable can aid in the management and tracking of the referral.
• Ignore limitations/exclusions: Pay careful attention to any limitations or exclusions noted in the referral form or in the patient’s health plan to avoid denied services.
• Use non-participating providers without approval: Referrals to non-participating providers require prior approval from Empire Medical Management. Avoid making such referrals without this crucial step.
• Forget to sign the form: The referral form needs to be signed by the referring physician to be valid. An unsigned form can result in processing delays or denials.

By adhering to these do's and don'ts, you can help ensure that the referral process is efficient and effective, minimizing the risk of errors or delays in patient care.

Understanding the Empire Referral Form is crucial for both patients and healthcare providers to ensure smooth access to necessary medical care. However, several misconceptions can lead to confusion and delays in receiving care. It is important to clarify these misunderstandings for better healthcare experiences.

• Referrals Are Optional: A common misconception is that referrals are optional for all types of healthcare services. This is not accurate. The Empire Referral form clearly indicates that referrals are mandatory for certain plans like HMO, Child Health Plus, Healthy NY, and others. Without a proper referral, patients might not be able to access specialized services.
• Any Service Provider Works: Another misunderstanding is the belief that the referral form can be used to see any healthcare provider. The form specifies that referrals are not valid for services from non-participating providers. To ensure coverage, patients must choose providers that participate within the Empire network.
• Referrals Cover All Services: Some people think that once they have a referral, it covers any medical service. The referral form clarifies that certain services like inpatient hospital admissions, emergency admissions, and surgeries not performed in the doctor’s office require separate approval from Empire Medical Management.
• Emergency Services Require Referrals: In urgent situations, some may worry that they need a referral for emergency services. This is not the case as the form excludes emergency and maternity admissions from needing a referral. Patients can seek immediate care without worrying about referral paperwork in emergencies.
• Unlimited Use of Referrals: There is a belief that once a referral is issued, it can be used repeatedly without limitation. The form details that referrals are valid for 90 days from the service start date unless specified otherwise. This limitation encourages timely use and ensures that referrals are still accurate for the patient’s current condition.
• Missing Information Is Overlooked: A significant misunderstanding is thinking minor errors or missing information on the referral form will be overlooked. The form mentions that if any required field is missing, the referral will not be accepted. This exemplifies the importance of carefully filling out every section to prevent denial of services.

Clearing up these misconceptions can enhance the efficacity of healthcare referrals, making sure patients receive the right care at the right time and from the right providers. Understanding how to properly use the Empire Referral Form is a step towards more efficient and effective healthcare coordination.

When dealing with healthcare, forms like the Empire Referral form play a critical role in ensuring patients receive the necessary approvals for their care. Understanding the key elements of this form can help both patients and healthcare providers navigate the process more smoothly. Here’s what you need to know:

• The form serves patients within specific health plans: It is essential for patients enrolled in HMO, Child Health Plus, Healthy NY, Direct Pay HMO, and Direct Pay HMO/POS plans. These plans require a referral for consultations with participating providers.
• Referral validity is limited: Referrals issued using this form are valid for 90 days from the service start date unless explicitly stated otherwise. This time frame emphasizes the need for timely medical consultation following the referral.
• Certain services are excluded from this referral form: The form outlines specific services, like those involving non-participating providers, inpatient admissions, and emergencies, among others. These require direct approval from Empire Medical Management.
• Completeness is critical: The form mandates the inclusion of several required fields. Missing any essential information will result in the referral not being accepted, which could delay the patient’s care.
• Details for both the referring and the referred-to physicians are necessary: To complete the referral, information about both the referring physician and the specialist to whom the patient is being referred must be filled out, including their names, addresses, and Empire provider ID or NPI numbers.
• The form is backed by reputable organizations: Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, provide the services indicated on the form. This affiliation ensures that the form complies with specific standards and regulations.

Navigating healthcare procedures can sometimes seem complicated, but understanding how to properly fill out and use essential documents like the Empire Referral form can significantly streamline the process. It ensures patients receive the timely and appropriate care they need while complying with policy requirements.