Patient Referral Form


PATIENT AND HEALTH INSURANCE INFORMATION
Patient Last Name

First

Middle



Group Name
Date of Birth (mm/dd/yyyy) Name of Policy Holder
Gender M F Goodhealth Policy Number
Local Address Effective Date of Policy (mm/dd/yyyy)
City
State End Date of Policy (mm/dd/yyyy)
Country
Home Phone No. ()
Emergency Contact Name Phone No. ()
HEALTH INSURANCE BENEFITS INFORMATION
Deductible:



 Co-Insurance %:



Policy Limitations:
TREATMENT REQUEST INFORMATION
Contact Name Main Phone No. Fax No.
() ()
Practitioner Specialty and Name
Date of Appointment (dd/mm/yyyy)

Time of Appointment

Address of Practitioner



TID Number

Diagnosis or Chief Complaint:

ICD Code:


 FOR ADDITIONAL MEDICAL INTERVENTION,
PLEASE CONTACT US FOR PRE-CERTIFICATION.
FAILURE TO DO SO MAY RESULT IN REDUCED
OR NON-PAYMENT OF A CLAIM.
Services Requested:


Diagnostic laboratory work, refer the patient to Quest Diagnostic or Labcorp Diagnostic Centers. Should you require assistance in identifying in-network providers, please contact Goodhealth Worldwide (Americas).
Submit claims and medical records to:
Goodhealth Worldwide (Americas)
Attention Claims Department
P.O. Box 144631
Coral Gables, Fl 33114
T. In USA: 1.800.914.2176 Out of USA: 1.305.443.6267
F. 1.305.443.6648
E. claims@goodhealthamericas.com

Final payments are subject to plan benefits, policy guidelines and PPO fee schedule allowance. HAA Preferred Partners, LLC is not a guarantor of claim payment and therefore all payment decisions are based on member’s policy guidelines. If you have any questions regarding coverage or require additional pre-certification of services please contact Goodhealth Americas Claims Department.