Managed Care Referral Request Form

Managed Care Referral Request
Current Date*

MonthDayYear
Member's Full name*

First NameMiddle InitialLast Name
Member's Date of Birth*

MonthDayYear
Member's SCHA ID Number*
The ID number from the South Country member ID card. It starts with a "G".

Primary Care Provider (PCP) Information

Please add referring primary care provider (PCP) information below.
Name of PCP*

First NameLast Name
PCP NPI*
Clinic Name*
Clinic Phone*
PCP clinic's phone number. Area code plus phone number.
Clinic Fax*
PCP clinic's fax number. Area code plus phone number.
Name of person completing this form*

First NameLast Name
Email of person completing this form*
example@example.com

Referral Information

Add the information for the specialist to which the member is being referred.
Clinic/Facility name*
Clinic/Facility National Provider Identifier number*
Specialty of the clinic/facility*
Clinic/Facility location (City & State)*
Clinic/Facility phone number*
Please enter a valid phone number.
Clinic/Facility fax number*
Please enter a valid fax number.
Referral reason*
Reason why the member is being referred.
Diagnosis*
Add start date when the member is authorized to receive services from the referral provider, and end date when the member is no longer authorized to receive services from the referral provider.
Start date*

MonthDayYear
End date*

MonthDayYear
Secondary prescriber authorization

Checking this option means the primary care provider authorizes the referral provider to prescribe medication.
Secondary prescriber name*

First NameLast Name
Secondary prescriber NPI*
For any questions, please call the Restricted Recipient Program Manager at 507-431-6370.

This form is used for members in the Restricted Recipient Program which requires a member's primary care provider to submit a referral to South Country for all specialists. This form will be faxed by South Country to the specialist to serve as notification that the member is authorized to receive care from the specialist.
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