Amazon PCP Referral Form

  • Primary Care Provider (PCP) Referral to Specialist

    The Primary Care Provider (PCP) must complete the Referral to Specialist form and submit or fax it to Premera Blue Cross before the member receives services from a specialist. If Premera does not receive this completed form before the services are delivered, the claim for the specialist’s services will be denied. Receipt and acceptance of this referral form does not guarantee a benefit nor does it constitute a benefit advisory. A referral form is not required for OBGYN, Chiropractic, Mental Health, Preventive, Substance Abuse, Ophthalmologist/Optometrist, Autism services. The member does not need approval in advance for treatment of life-threatening conditions or urgent and emergency care.

    Section 1. Member Information

    Last Name First Name Middle Initial  
    Member ID   Date of Birth
    1. Gender
    Home Address (no PO Box) Telephone Number  

    Section 2. Provider Information

    Referral start date  
    Referral end date (If not dated, referral ends after one year)
    1. Standing Request
    Referring Provider Information 

    Last Name First Name Middle Initial  
    Tax ID number or Social Security Number  
    Service location address (no PO BOX)  
    Billing Address  
    Telephone Number  

    Covering Provider Information 

    Last Name First Name Middle Initial  
    Tax ID number or Social Security Number  
    Telephone Number  

    Section 3. Specialist information

     
    Last Name First Name Middle Initial  
    Tax ID number or Social Security Number  
    Location address (no PO Box)  
    Billing address  
    Telephone number  

    I certify that all information I have provided in this form is accurate and complete to the best of my knowledge. I understand that any false statement or misrepresentation of the information I have provided on my referral request will be grounds for rejection of claims arising from this referral. I also understand that receipt and acceptance of this referral form does not in any way indicate that any services provided subsequent to this referral are assured of benefits coverage under this plan. Coverage of service information and confirmation of benefits must be sought through the other normal channels available (call Premera Customer Service at 877-995-2696).

     

  • Customer Service
    877-995-2696 

    Fax
    888-617-0495