FamilyCare Health Plans Referral/Auth Form
825 NE Multnomah, Suite 300, Portland, OR 97232 Referral Dept.
Ph: 503-228-8228 or 800-684-3799
Fax: 503-345-5770 or 800-270-7737
**Please check requested service**

Urgent Request (Please contact referral and auth dept if unclear if request meets urgent criteria)
Today's date: Click here to enter a date.
Name of Contact:  
Primary Care Physician
Initial Specialist (First, Last):
Phone #:  
Fax #:  
  Send Notification Email
Member Name (First, MI, Last):  
Recipient ID #:  
Requested Specialist/Facility Name:  
Phone #:  
Fax #:  
Diagnosis with ICD-9 Code:  
Start/Scheduled Date of Service: Click here to enter a date.  
# of visits requested:  
CPT code(s) required for surgery:
Check place of service:
Home Health
Discipline Revenue Code(s) # of Visits per day # Days
Add attachment:


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