Submit a Referral – INTERLINK Transplant

INTERLINK will provide the financial terms of an in-network facility to you within 48 hours of referral receipt. For out-of-network referrals, INTERLINK will begin negotiations with the facility immediately and keep you up to date as we proceed Referrals are free to submit. If you need support, please contact us at 877-599-9119 or accountmanagers@interlinkhealth.com

Referral Communication Contact

Name(Required)

Company(Required)

Email(Required)

Phone(Required)

Patient Information

Name(Required)

First Last

Date of Birth(Required)

Age

Address

Street Address City State ZIP Code

Facility/Service Information

Type of Service(Required)

Facility(Required)

Out of Network Facility

City

State

Evaluation Date

Organ Source

Diagnosis

Health Plan Information

Type of Plan(Required)

Payer (Entity Bound by Terms of Agreement)(Required)

Name of entity signing agreement if different from employer group (N/A if same)(Required)

Insured ID(Required)

Reinsurance/Stop Loss Carrier(Required)

Name

First Last

Managing General Underwriter (MGU)

Claims Payment Information

Company(Required)

Contact(Required)

Address

Street Address City State ZIP Code

Email(Required)

Phone

Case Manager Information

Company(Required)

Contact(Required)

Address

Street Address City State ZIP Code

Name

First Last

Email(Required)

Phone

Whom Should The INTERLINK Access Fee Invoice Be Sent To

We recommend verifying reimbursement or coverage of this fee with your reinsurance or stop-loss carrier.

Name(Required)

Email(Required)

Phone(Required)

Other

Candidate Education Booklet(Required)

Additional Comments

CAPTCHA

Referral Communication Contact

Patient Information

Facility/Service Information

Health Plan Information

Claims Payment Information

Case Manager Information

Whom Should The INTERLINK Access Fee Invoice Be Sent To

Other

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