First, separate the documents
A PCP referral and payer prior authorization are different requirements. HealthCare.gov describes a referral as an order from a primary care clinician for specialist care, while prior authorization is a health plan’s approval that may be needed for coverage. Check which document is missing instead of assuming one satisfies both.
| Document | What your office needs to establish |
|---|---|
| PCP referral | Whether the appropriate clinician-issued referral has been supplied for this patient and specialist. |
| Payer authorization | Whether the plan’s separate approval requirements have been met for the relevant service. |
Sources: HealthCare.gov: referral and prior authorization.
1. Confirm exactly what is missing
Check the scheduling record, existing referral documents and your office’s current plan instructions. Identify the patient’s PCP practice, the requested specialist and the document you need returned. If responsibility is unclear, confirm it with the PCP or plan before sending repeated requests.
Use the receiving office’s required form or portal when applicable. A generic fax template does not establish that a particular plan accepts fax requests.
2. Verify the receiving office and return fax
Confirm the PCP practice’s current referral fax destination through an authoritative office source or directly with its staff. A practice’s main fax and its referral-processing fax may differ. Check your return fax as carefully as the destination.
HHS identifies confirming the intended recipient’s fax number as an example of a reasonable safeguard. See HHS guidance on faxing between physician offices.
3. Prepare a request the PCP office can act on
Gather the patient identifiers needed for matching, the requesting practice and specialist, the requested specialty, the reason supplied by your clinical team, and any supporting documents the receiving office requests. Add relevant dates and clear reply instructions. Include plan/member information when needed for that office’s process.
Staff should use clinical details supplied by the appropriate clinician rather than inventing a diagnosis or presenting the request itself as clinical approval.
Download the blank request template →4. Review and send through your office’s approved process
Review the patient match, destination, return fax and every attachment. If sending through FaxSeal, review the exact PDF and quote before confirming. PCP Requests real sending requires office activation, an applicable agreement and shared credits; availability remains subject to service readiness.
Keep the delivery record with the request. A transmission marked delivered does not prove that staff reviewed it or that the referral or payer requirements are complete.
5. Assign follow-up and review the reply
Give the request a staff owner, next action and follow-up date based on your office’s process and what the PCP office tells you. There is no universal response deadline for this general template.
When a reply arrives, verify the patient, specialist and requested document. Review referral status and payer authorization separately. Staff decide what remains outstanding under the office’s scheduling process; receiving a reply does not automatically mean the patient is ready to schedule.
Common questions
Is this the same as sending a referral to a specialist?
No. This workflow asks the PCP to provide a missing referral. Sending an existing clinician-approved referral to a specialist is a different task.
Can every specialty use the template?
The specialty field is blank. Your office can adapt the request to its specialty, while checking the PCP’s and plan’s actual requirements. It is not a plan-approved form.
Do PCP offices need a FaxSeal account to reply?
No. They can use the return instructions and their existing fax process. Staff in the requesting office still need to attach and review the response.