Molina Healthcare of Florida (MHF)
In-Network Specialist Referral Form
Date:
Patient Name:
DOB:
Member ID:
THIS REFERRAL IS VALID FOR 90 DAYS OR UP TO 6 MONTHS ONLY.
(A referral is not required for visits to providers with the following specialties –
Obstetrics and Gynecology, Dermatology, Chiropractic and Podiatry)
1. Provide original form to Member to be presented to specialist.
2. Forward a copy to requested specialist.
3. Place a copy in Member’s medical record.
4. Include all necessary clinical information with this referral.
Diagnosis Description: ICD 10 Diagnosis Code:
Referred To:*
_____________________________
*Must refer to a specialist within network
Specialty: ________________________________
Address: _________________________________
_________________________________
Specialist Phone Number: ___________________
Specialist Fax Number: _____________________
Check one:
[ ] Standard Referral (up to 3 visits for 90 days)
[ ] Standing Referral. Enter the number of
visits_______. Standing referrals are valid for up
to 6 months.
Clinical Reasons for Referral:
Requesting PCP:
Phone Number:
Fax Number:
Signature:
Date:
Version 022018
