- Publicforms

Available Forms

Alignment Care Center Appointment Request Alignment Referral Form Back Pain E-Visit Blood Pressure Log Blood Sugar Readings Cold/Sinus/Cough/Throat/Respitory Infaction E-Visit Conjunctivitis/Pink Eye E-Visit Depression Screening (PHQ9) Health Care Question Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam Prescription Refill Request Referral Question Specialist/Urgent Care or Hospital Visits Survey Triangle Medical Group Urinary Tract Infection E-Visit Yeast Infection E-Visit

Alignment Referral Form

PRIOR AUTHORIZATION REQUEST ALIGNMENT HEALTHCARE

For assistance contact the Referrals/Authorization Dept at 844-215-2442

Practice Location *

Date *

Please choose either primary MD or FNP/PAC

PCP MD

Primary FNP/PAC

Type of Referral

Urgent

Routine

Health Plan Member ID *

Last Name Patient

First Name Patient

Sex *

Male

Female

Date of Birth *

Address

City

State

Zip Code

Type of Service

Referred to

Specialty

Primary Diagnosis

Secondary Diagnosis

ICD-10 Codes

Proceedure

CPT CODE

Clinical Justification (Send Progress Notes/diagnostic studies)

Referring Physician

Person Completing Form

Telephone Number

DO NOT COMPLETE SECTION BELOW

Tracking Number

Expiration Date

Status

Approved

Deferred

Modified

Denied

Reason Not Approved

Specific Instructions

Alignment Healthcare Staff

Medical Director Signature

Date

Time

Choose either the primary MD or FNP/PAC

* Required field