1916 Medical Arts Drive, Huntingburg, in 47542-9521

1916 Medical Arts Drive, Huntingburg, IN 47542-9521

Phone: 800-318-1590 812-683-3332 Fax: 812-683-5634 Fax: 812-683-5634 www.pvcooperative.com

Out-of-Network-Referral-Form

All blanks MUST be filled in

Patient Name:______Male / Female

Patient Address:______City/State/Zip______

Patient SSN:______Patient DOB:______Patient Phone No:______

Patient Relation to Insured: Self Spouse Child Other____

Insured Name:______

Insured SSN:______Insured Employer:______

Group #______

Referring Doctor:______Speciality:______

Address:______

Phone Number:______Tax ID:______

Consulting Physician/Facility:______Speciality:______

Address:______

Phone Number:______Tax ID:______

Diagnosis for Referral: BOTH ARE REQUIRED

Code:______Definition:______

Medical Reason to go out of network:______

______

___ Second Opinion Only. ___Evaluate and Treat not to exceed 1 year

------Signature of Provider Printed Name Date

Serving Crawford, Daviess, Dubois, Martin, Orange, Perry, Pike, Spencer & parts of Gibson & Warrick Counties. fshared/referrals/2014-12-26-referral form.docx Version: 12/26/14