Additional Networks Homepage » VAD/Cardiac » Submit A Referral

Submit A Referral

VAD/Cardiac

Please use this form to submit a referral to INTERLINK Health Services Inc. for an AdditionalNETWORKS Service. Fill out the form completely and click "Submit" to immediately send your referral to INTERLINK.

NOTE:  INTERLINK will provide the financial terms of an in-network facility to you within 48 hours of referral receipt.  To help us continue to process your referral in a timely manner, please provide all requested information.

Contact Information
Name:
Company:
Street Address:
City, State, Zip:
Email:
Phone:
Fax:
Patient Information
Patient Name:
Patient Residence Street Address:
City, State, Zip:
Employer Group Name:
Employer Group City, State:
Insured ID:
Date of Birth:
Sex:
Procedure Information
Procedure Type:
ICD-10 Code:
Age:
Diagnosis:
Evaluation Date:
Facility Information
Name:
City, State:
Case Management Information
Case Manager:
Company:
City, State:
Phone:
Email:
Reinsurer or MGU Information
Reinsurer:
Company:
City, State:
Contact:
Phone:
Email:
Claims Payment Information
Company:
Contact:
Street Address:
City, State, Zip:
Phone:
Fax:
Email:
Benefit Coverage Information
Health Plan Coverage Primary:
Medicare Advantage Plan:
Group Renewal Date:
Type of Plan:
Additional Comments: