1. click here to print out the Outpatient Referral Form.
2. Fill out the form, leaving the Form Number box blank.
3. Make 1 copy. Give the original to the patient, and keep the copy for the office records.

To download information on pre-authorization requirements, click here.

To download information on Categories of Prescription Drugs with Quantity Limits, click here.

To down load a list of injectables, which require pre-authorization and are available from Maxor Mail Order, click here.

To download information on Tier 3 (Non-formulary brand name medications), click here.

To download information on TRICARE Uniform Formulary exclusions, click here.

To download the Brand Name Request form (providers only), click here.

To download the Quantity Override Request form (providers only), click here.

For additional pharmacy information, contact Maxor Plus at 800-687-0707 or visit their web site at www.maxor.com.

• Submit Medical Claims Electronically via WebMD, Payor ID 13407.
• Use ONLY updated or current diagnosis and procedure codes.
• USFHP members cannot be balanced billed for any amounts in excess of the allowed amount, other than for copayments and coinsurance.
• USFHP is always primary to Medicare with few exceptions. Do not bill Medicare or Medicaid.
• Claims status can be checked online by accessing the Provider Portal by clicking here or by dialing 212-868-9447 and accessing our Fax Recall system.