Network Service Availability Form

If you are you receiving a referral outside of the Prisma Health Network oyu will need to fill out this form and download the pdf. Then submit it with the Network Exception Referral Form

This form is not intended for prior authorizations or pre certifications. If you have a question about prior authorizations or pre certifications, contact Allegiance Customer Service at 1-855-999-2271.

All fields required to be filled out by members only. Incomplete forms or forms filled out by a physician will not be honored.

Date Patient Name Plan Selection Member Id Number Home Address Referring Provider Diagnosis Type of Service Required Type of Specialist Required Treatment Period New or Existing Treatment How often is treatment? Facility/Practice you are being referred to Facility/Practice more info Reason for Referral Reason for Referral more info