Referral and Authorization - EOCCOEastern Oregon Coordinated Care Organization RUSH RETRO Call/fax received by _____ Date call/fax received _____ Referral Service Authorization Flexible
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Eastern Oregon Coordinated Care Organization Patient Information Patient Name____________________________________________ DOB _________________ OHP Client ID # ____________________________ Group # ______________ PCP/On Call Doctor Information PCP/On Call Doctor ___________________________________TIN # ______________________________________ Ph#_______________________________Fax # _____________________________Contact ____________________ Specialist Information Specialist Name ______________________________ TIN# ______________________________________________ Ph#_______________________________Fax# ____________________________Contact ______________________ Address/Location_______________________________________________________________________________ Facility Information Facility ______________________________________________TIN #_____________________________________ Ph # ______________________________ Fax#____________________________Contact _____________________ Admit Date_____________________Discharge Date_____________________ Additional authorization/referral information ICD10 code(s)_______ _______ _______ _______ _______HCPC code(s)_______ _______ _______ _______ _______ Comments: For EOCCO use only: Authorization Number _____________________________Denial Number___________________________ Referral and Authorization CPT code(s) _______ _______ _______ _______ _______ _______ _______ _______ Date span requested _________________ to _________________ #of visits/Inpt nights requested__________ Is this for a second opinion Yes No (503) 243-4496 (800) 258-2037 Fax (833) 949-1886 PO Box 40384 Portland, OR 97240
Are you referring to an Out of Network Provider? Yes No
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If Yes, I attest this is the only Provider who can treat this condition
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RUSH (ONLY for cases in which a Provider indicates that following the standard time frame could seriously jeopardize the members life or health or ability to attain, maintain or regain maximum function
