Seeing patients without authorization/referral
If a patient wants to be seen, but he or she has not obtained the necessary authorization or referral from his/her primary care physician (PCP), have him or her complete the Patient Acknowledgment of Financial Responsibility form.
A separate form is required for each date of service.
Use the Patient Acknowledgment of Financial Responsibility form, or your office's equivalent, when:
- Services have not been authorized by the member's PCP
- Services have been authorized by the PCP, however, the PCP has not notified your office of the referral
- Services requested by the patient are not covered
Required information
If your office uses a different form, it must be date-of-service specific (not a general waiver) and include this information:
- Date of service
- Patient name
- Physician name
- Patient signature and date
- Description of services being performed
Get the Patient Acknowledgment of Financial Responsibility form (103KB PDF)
