To: Hoag Eligibility Team

Note:  The patients in your patient list in EpicLink represent all patients with (1) an active referral, (2) assigned to you as a PCP, or (3) with a 2022 claim.  If you see missing patients, please use the Search All Patients function before filling out this form. If a patient is missing HMO/MA coverage in EpicLink, please verify coverage and fill out this form with their current coverage information.  

This form should not be used to add PPO or EPO patients to EpicLink, including the Hoag Employee EPO plan.  PPO/EPO authorizations are managed by the Health Plan (i.e. Cigna, etc.) and, therefore, you will not use EpicLink to submit referrals and authorizations.  

Search All Patients Function: You will need the patients date of birth, gender, and an exact name match. If you add additional information (i.e. City, Phone) you will have a better chance of successfully finding the patients.  Please note:  misspellings or partial names (i.e. Sue vs. Susan) will not successfully match the name - name must exactly match the name as it is found in EpicLink.

For urgent requests, please fill out form and email eligibility@hoag.org




Date/Time*
:  
From*
Physician Name*

Patient Information #1

Please check the eligibility for the following HMO Member(s) who are assigned to the above PCP and are not found on the Provider Portal or the PCP's CAP Member Roster Report

Patient Name*
Patient Date of Birth*
Patient Eligibility has been verified*
Health Plan website links and phone numbers can be found at www.hoaghealth.org/hpp

Patient Information #2

Please check the eligibility for the following HMO Member(s) who are assigned to the above PCP and are not found on the Provider Portal or the PCP's CAP Member Roster Report

Patient Name*
Patient Date of Birth*
Patient Eligibility has been verified*
Health Plan website links and phone numbers can be found at www.hoaghealth.org/hpp

Patient Information #3

Please check the eligibility for the following HMO Member(s) who are assigned to the above PCP and are not found on the Provider Portal or the PCP's CAP Member Roster Report

Patient Name*
Patient Date of Birth*
Patient Eligibility has been verified*
Health Plan website links and phone numbers can be found at www.hoaghealth.org/hpp

Patient Information #4

Please check the eligibility for the following HMO Member(s) who are assigned to the above PCP and are not found on the Provider Portal or the PCP's CAP Member Roster Report

Patient Name*
Patient Date of Birth*
Patient Eligibility has been verified*
Health Plan website links and phone numbers can be found at www.hoaghealth.org/hpp

Patient Information #5

Please check the eligibility for the following HMO Member(s) who are assigned to the above PCP and are not found on the Provider Portal or the PCP's CAP Member Roster Report

Patient Name*
Patient Date of Birth*
Patient Eligibility has been verified*
Health Plan website links and phone numbers can be found at www.hoaghealth.org/hpp
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