Seeing Patients W/out 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)