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Referring office information
Provider First Name
Provider Last Name
Provider NPI Number
Practice Name
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
Phone
Fax
Office Contact
Patient information
Patient First Name
Patient Last Name
Date of Birth
Patient Phone
Marital Status
Divorced
Life Partner
Married
Separated
Single
Unknown
Widow/Widower
Gender
Female
Male
Unspecified
Social Security Number
Insurance Type
Aetna
BCBS Federal Plan 104, 105, 106
BCBS Federal Plan 111, 112, 113
BCBS HMO/EPO
BCBS HMO/EPS and PT States OON Benefits
BCBS Horizon
BCBS of WV Highmark
BCBS PPO/POS
BCBS, Unknown if PPO/HMO
Blank
Cigna HMO
Cigna HMO & PT Lives in GA, IL, PA, OK, NY, CT, DE, AZ, or NJ
Cigna PPO
Cobra
Commercial HMO/EPO
Commercial HMO/EPO and PT States OON Benefits
Commercial PPO/POS, PT doesn't know Ins Co
Commercial PPO/POS, PT knows Ins Co
Commercial, PT Knows Ins Co, doesn't know HMO/PPO
Commercial, Unknown Ins. Name and Unknown PPO/HMO
Coventry National
CTCA Insurance/Employer Exclusion
First Health
Health Choice
Humana
Insurance Alert List
International Plan
Medicaid
Medicare
Medicare/HMO
Medicare HMO Advantage BCBS of AZ
Medicare UHC Advantage
No Insurance
No insurance – Self Pay Declined
Presbyterian Health
Self Pay
Tri-Care Prime
Tri-Care Stand
UHC Options PPO
Unknown
VA
Insurance Provided By
Cobra
Employer/Spouse Employer
Government
Individual
Unknown
Diagnosed Date
Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
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Our pledge to referring physicians
We will:
Provide an easy and efficient process for your patient referrals
Maintain a dedicated referral phone number
Treat your patient with the highest degree of respect and care
Ensure an efficient and timely insurance verification process
Promptly schedule your patient's appointment
Provide you with helpful access to the physician treating your patient
Swiftly respond to your requests for patient status updates
Collaborate with you to appropriately and deliberately transition patients back to your care