Trilogy Referral Form


Referral Form

To submit this referral online fill in the blanks below then click the SUBMIT button at the bottom of the page. 

TRILOGY AUTHORIZATION FORM

• Diagnostic Procedure – Physician Order
• Durable Medical Equipment (Purchase or Rental) – Physicians Order & State Prior Auth/Oxygen Attachment
• Durable Medical Equipment (Repair) – Physicians Order and Work Order
• Home Health – 485 Form
• Hospice – State Physician Certification & Recertification of Terminal Illness
• PCW – PA/RF & HCAF & 485 & PCW Instructions
• Rehabilitation – Physician Order & Initial Evaluation
• RN Supervisory – PA/RF & HCAF & 485 & PCW Instructions
• Therapy (PT/OT/SP)requires Physician Order & Initial Evaluation

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