Managed Care Referral Request Form

For members of the Restricted Recipient Program only, this form is used to refer a member to a specific provider.

Step 1 of 3 - Member Information

Date(Required)

Add date when form is filled out. Month, day, year.

Member Full Name(Required)

The first name, middle initial, and last name of the member.

Date of Birth(Required)

The birth date of member. Month, day, year.

Member ID Number(Required)

The ID number from the South Country member ID card. It starts with a "G".

Primary Care Provider (PCP) Information

Add referring primary care provider (PCP) information below.

Name of the Primary Care Provider (PCP)(Required)

First Last

PCP NPI(Required)

Primary care providers National Provider Identifier number.

Clinic Name(Required)

Name of the primary care provider's clinic.

Clinic Phone(Required)

Primary care provider clinic's phone number. Area code plus phone number.

Clinic Fax(Required)

Primary care provider clinic's fax number. Area code plus fax number.

Completed by(Required)

Name of the person completing this form.

First Last

Email of Person Completing Form(Required)

Add the email address of the person completing this form. We require this for HIPAA submission of this form.

Referral Information

Add the information for the specialist to which the member is being referred.

Clinic/Facility Name(Required)

The name of the clinic or facility.

Clinic/Facility NPI(Required)

National Provider Identifier number for the clinic/facility.

Specialty(Required)

Specialty of the clinic/facility.

Clinic/Facility Location (City & State)(Required)

The city and state where the clinic/facility is located.

Clinic/Facility Phone(Required)

Telephone number of the clinic/facility. Area code plus phone number.

Clinic/Facility Fax(Required)

Fax number of the clinic/facility. Area code plus phone number.

Referral Reason(Required)

The reason why the member is being referred.

Diagnosis(Required)

Start Date(Required)

Start date when member is authorized to receive services from referral provider. Month, day, year.

End Date(Required)

End date when member is no longer authorized to receive services from referral provider. Month, day, year.

Secondary prescriber.

Checking this box means the primary care provider authorizes the referral provider to prescribe medication.

Secondary Prescriber authorized.

Secondary Prescriber Name(Required)

Name of the secondary prescriber.

Secondary Prescriber NPI(Required)

National Provider Identifier number for the secondary prescriber.

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.