Specialist Referral Form - Mercy Care · (800) 564-5465. SPECIALIST REFERRAL FORM . Patient Information . Date: _____ Member AHCCCS ID: _____ DOB:File Size: 1MBPage Count: 1

(800) 564-5465

SPECIALIST REFERRAL FORM

Patient Information Date: _________________________

Member AHCCCS ID: _____________________ DOB: _________________________

Patient Name: ___________________________

Patient Address: ______________________________________________________________

Patient Phone: _________________________ Work Phone: _______________________

Primary Diagnosis: ______________________

Reason for Referral: ___________________________________________________________

Requesting Primary Care (PCP) Information

PCP Name: ___________________________________________

PCP Location: ________________________________________________________________

PCP Phone: ____________________________ PCP Fax: __________________________

Specialist Information

Specialist Name: _________________________ Specialty: ________________________

Specialist Address: ____________________________________________________________

Specialist Phone: _____________________________

Number of specialist visits requested by PCP: _____________________________

PCP Signature: ______________________________________________________