High call volumes

Our provider services may be experiencing higher than normal call volumes this week. We encourage you to utilize alternative forms of communication, such as the Availity Essentials Provider Portal

TEST - Preferred Provider Referral Form

This form is intended for submission by Preferred Providers within a tiered network product who are not part of the tiered network health system. If you are a provider outside of the Preferred network, please submit your referral through Availity Essentials.

Member Information

Member First Name

Member Last Name

Member Date of Birth

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Member ID

Referred to

Provider Name

Contact Phone Number

Specialty

Provider NPI

Facility Name

Referred by

Contact Name

Contact Phone Number

Contact Email

Specialty

Provider NPI

Facility Name

Is this a referral review or a denial notification? Referral Review

Denial Notification

Rationale for referral

Diagnosis Code(s)

Start Date

Please enter a valid Date.

End Date

Please enter a valid Date.

Number of Visits

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Fargo, N.D., 58121

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TEST - Preferred Provider Referral Form

Member Information

Referred to

Referred by