Mail to:
Gateway Health Plan®
P.O. Box 69360
Harrisburg, PA 17106-9360
GATEWAY HEALTH PLAN ®
REFERRAL FORM
CAHL000705
For claims payment purposes each referral you issue
requires a NEW form to be downloaded and printed.
Just print, complete and mail to the address on the form.
PRIMARY CARE INFORMATION
PCP Name: ____________________________
PCP Address: __________________________
Automated telephone referrals may be done through Gateway’s
DIVA/EVS line at 1-800-642-3515.
PATIENT INFORMATION
Patient Name: ____________________________
__________________________
Gateway Member ID# __ __ __ __ __ __ __ __ __
PCP Phone: ___________________________
Diagnosis/Complaint:
________________________________________
PCP Group Provider ID #: __ __ __ __ __ __
Designated Laboratory:_____________________
SPECIALTY PROVIDER OR FACILITY INFORMATION
SPECIALTY PROVIDER - Complete specialist name and provider group ID for services rendered at office site only.
FACILITY PROVIDER -
Complete facility name and facility ID for services rendered at outpatient facility to allow
both facility and physician services to be covered.
REFERRED TO:
Provider Name: _____________________________________
Provider Group or Facility ID Number: __ __ __ __ __ __ __
____ Office Visit - 3 Visits/90 Days
____ Allergy Services - 9 Visits/90 Days
____ Laboratory Testing Performed by a
Non-Designated Lab
____ Pain Managment - 9 Visits/90 Days
Must use the member’s designated
laboratory except in an emergency.
No referral needed when member
is referred to their designated lab.
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The referral must be in Gateway’s claim system at the time the bill is received to be applied to the service rendered.
Payment for referral and precertified services is contingent upon the patient being an effective Gateway member on the date of service at the
time of claim processing.
PCP Signature: __________________________________________(An Unsigned Form is Invalid)
Referral Date: ______-______-_______ (If referral is not dated, Gateway will date according to receipt at the
claim office.)
Rev. 01/13