Can this document be signed electronically?

Yes. Under the federal ESIGN Act (15 U.S.C. ch. 96) and state UETA laws, electronic signatures are generally valid for most transactions, provided intent, consent, attribution, and retention are demonstrable.

When is a notary or witness required?

Notarization or witness requirements depend on state law and the document's purpose. Some states require witnesses for certain instruments; rely on state rules or counsel for transactions needing notarization or self-proving affidavits.

Are remote online notarizations allowed?

Many states permit RON with identity proofing and audio-video recording, but rules vary. Check the state notary commission or NCSL guidance before using RON for required acknowledgements.

How do I correct or amend a submitted plan?

Create a dated amendment or superseding plan that references the original, obtain required signatures, and retain both versions to preserve auditability and show change history.

Who should keep the master record?

The primary clinical or administrative record system should retain the master signed copy; additional copies may be stored in secure archives with access controls and retention consistent with policy.

What if a signer disputes the signature?

Preserve the audit trail (timestamps, IP, authentication method), any identity verification records, and related communications; these items support attribution and help resolve disputes.

Referral Action Plan

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

REFERRAL ACTION PLAN

This Referral Action Plan ("Plan") is entered into on by and between Referrer Name: and Recipient Name: .

WHEREAS

WHEREAS, Referrer maintains relationships and marketing channels that may generate prospective clients or customers that could be suitable for Recipient's products or services; and

WHEREAS, Recipient desires to engage Referrer to identify, pre-qualify and submit prospective referrals on the terms set forth in this Plan in exchange for referral compensation and other obligations stated herein; and

WHEREAS, the parties intend by this Plan to define the scope, timing, payment terms, confidentiality obligations, and dispute resolution parameters governing referral activities.

SCOPE OF WORK

Description of Referral Activities

REFERRAL DETAILS

Target Industry / Client Profile Expected Referral Volume Referral Submission Method

Valid referral will be deemed to have occurred when Referrer provides Recipient with the prospective client's name, contact information, and a brief qualification summary and Recipient confirms receipt in writing within days.

PAYMENT TERMS

Referral Fee: Recipient shall pay Referrer a referral fee equal to of the net revenues actually received by Recipient from the referred client for the first following the first paid transaction.

Payment Schedule / Invoicing

Late Payment: Any undisputed amount not paid within days after the due date shall accrue a late fee of , compounded monthly, or the maximum permitted by applicable law, whichever is less.

TERM AND TERMINATION

Term Commencement: This Plan commences on and continues until unless earlier terminated as provided below.

Termination: Either party may terminate this Plan for convenience upon written notice to the other party at least days prior to termination. Either party may terminate immediately for material breach that remains uncured after days' written notice.

CONFIDENTIALITY

Each party shall hold in strict confidence and shall not disclose to any third party any Confidential Information of the other party, except as necessary to perform under this Plan or as required by law. "Confidential Information" includes referral lists, contact data, business processes, pricing, and any non-public materials marked or reasonably understood to be confidential. Confidentiality obligations survive termination of this Plan for a period of three (3) years.

Confidentiality Acknowledgement

Referrer and Recipient acknowledge and agree to the confidentiality provisions set forth above.

GOVERNING LAW

This Plan shall be governed by and construed in accordance with the laws of the jurisdiction of without regard to conflict of laws principles. The parties agree that any dispute arising out of this Plan shall be resolved in courts of that jurisdiction unless the parties agree in writing to arbitration.

ENTIRE AGREEMENT

This Plan, together with any written attachments or executed amendments, constitutes the entire understanding between the parties with respect to the subject matter herein and supersedes all prior discussions, proposals and agreements, whether oral or written. No amendment or waiver shall be effective unless in writing and signed by both parties.

NOTICES

Referrer Address for Notices Recipient Address for Notices

ADDITIONAL PROVISIONS

Exclusivity

The parties agree that referrals under this Plan are non-exclusive unless the parties check the box above to indicate exclusivity and specify terms in writing.

Special Conditions or Amendments

Referrer - Printed Name:

By:

Date:

Recipient - Printed Name:

By:

Date:

What a Referral Action Plan Is and when it matters

Referral Action Plan is a structured document that records a referring party's instructions and expectations when transferring a client, patient, or case to another provider or specialist. It lists the referring and receiving parties, reason for referral, required attachments, priority level, planned next steps, and signature blocks to confirm authorization. Organizations use the plan to reduce information gaps, create an auditable handoff, and support billing, scheduling, or clinical follow-up by establishing clear responsibilities and timelines for everyone involved.

Why a clear Referral Action Plan improves outcomes

A concise Referral Action Plan aligns expectations, documents consent, reduces missed follow-ups, and creates a defensible record for compliance. It clarifies who does what and when, supports timely billing and clinical decisions, and lowers the risk of errors that cause delays or denials when filled out and retained properly.

Who commonly completes and relies on this plan

Common users include clinicians, case managers, and administrative teams who coordinate referrals across clinical, legal, and operational workflows.

Primary care clinicians managing patient transfers and handing off clinical notes to specialists.
Case managers coordinating multi-agency services, appointments, and follow-up for complex cases.
Administrative staff responsible for routing, recordkeeping, and ensuring required authorizations are attached.

Assign completion tasks to the role with authority for each field; keep copies in primary record systems and follow organizational retention policy.

Roles that sign or authorize the plan

Referring Clinician

A licensed clinician or authorized agent who records clinical rationale, urgency, and required tests or attachments. Accurate clinical entries and clear instructions reduce delays and support appropriate triage by the receiving provider; mismatches can create clinical risk or billing complications.

Receiving Provider

The accepting clinician or team who documents appointment details, acceptance status, and any required pre-visit steps. Their acknowledgement confirms responsibility for evaluation and creates the receiving-side record needed for quality review and continuity of care.

Essential components to include in every Referral Action Plan

A professional plan consistently captures six areas: parties, clinical reason, supporting documents, timeline, contacts, and signatures to make handoffs auditable and actionable.

Parties

Full legal names and organizational details for referrer, recipient, and the client or patient to prevent misrouting and to tie the plan to official records.

Reason

Clear clinical or business rationale specifying symptoms, suspected condition, or business need so the receiving party can prioritize and prepare appropriately.

Attachments

List and attach required items such as labs, imaging, prior authorizations, or referral forms so the receiving party has the necessary documentation at intake.

Timeline

Requested appointment window, urgency designation, and any statutory or payer deadlines that affect scheduling and authorization.

Contact Info

Direct phone, secure messaging, and administrative contacts for both sides to resolve questions quickly and reduce scheduling friction.

Signatures

Authorized signature block with printed name, role, and date to document consent and delegation; include witness or notary fields if required by law or policy.

Step-by-step: completing and sending the Referral Action Plan

Follow these sequential steps to ensure the plan is complete, authorized, and received by the appropriate party without delay.

01

Prepare: Gather clinical notes, attachments, and payer authorizations before you begin.
02

Complete Fields: Enter required data accurately and use MM/DD/YYYY for dates.
03

Attach Documents: Upload lab reports, imaging, and authorizations as named attachments.
04

Send and Track: Route to the recipient, confirm receipt, and log acknowledgements.

Configuring an online referral workflow

Set up consistent templates, signer order, and notifications to reduce manual steps and speed processing when using an electronic platform.

Template Naming Convention	Use descriptive names including department and specialty to prevent misuse.
Signer Order and Roles	Define who signs first and which fields are role-restricted.
Authentication Method	Choose email link, SMS code, or stronger verification based on sensitivity.
Required Attachments Rule	Make key attachments mandatory to move the workflow forward.
Notification Settings	Enable delivery receipts and escalation alerts for overdue items.

Where to file or send the completed plan

Decide on primary retention and distribution points so each copy is available to the right stakeholders and complies with recordkeeping rules.

Electronic Health Record: Save a signed copy into the patient's EHR for primary clinical recordkeeping.
Recipient Inbox: Send a secure copy directly to the receiving provider or team mailbox.
Payer Portal: Upload authorizations or referral forms to insurer portals where required.
Shared Archive: Store an administrative copy in a secure document repository with access controls.

Digital signature and platform requirements

Choose a platform that supports required authentication, audit trails, and the file formats your organization uses.

Integrations: Salesforce, EHR, NetSuite
File Formats: PDF, DOCX, HTML
Authentication: Email, SMS, KBA options

Typical timelines and processing expectations

Operational timelines vary by organization and urgency; document them in the plan and communicate expectations to all parties.

Acknowledgement Window:

Confirm receipt within 24–48 hours for routine referrals.

Urgent Response:

Schedule an urgent evaluation within 48–72 hours as indicated.

Standard Appointment Target:

Aim for specialist appointment within 14 calendar days for non-urgent referrals.

Payer Authorization Timeframe:

Allow up to 30 days for insurance preauthorization workflows when required.

Case Closure:

Document closure or transition within 90 days unless ongoing care is indicated.

Key milestones from referral to closure

A concise milestone view makes responsibilities visible and supports escalation when milestones slip past planned dates.

01

Referral Received

Initial intake and verification of attachments and identifiers.

02

Contact Acknowledgement

Recipient confirms acceptance or requests clarification.

03

Specialist Appointment

Appointment scheduled and pre-visit requirements communicated.

04

Case Closure

Outcome documented and copies routed to originating records.

Common mistakes to avoid when preparing the plan

Omitting required attachments such as lab results or authorizations, which commonly delays processing and may cause denials.
Using inconsistent or abbreviated names and identifiers that lead to misrouting and data reconciliation errors downstream.
Failing to indicate urgency or next-step deadlines, which causes scheduling backlogs and reduced quality of handoffs.
Allowing unauthorized staff to complete signature fields, which can invalidate consent and create compliance exposure.

Risks and potential penalties of incorrect or incomplete plans

Data Breach Fines: Significant regulatory penalties

Regulatory Noncompliance: Civil fines and corrective action

Clinical Delay: Patient harm and liability risk

Billing Denials: Lost reimbursement and appeals

Contract Disputes: Litigation exposure

Invalid Referral: Care interruption or rework

Real-world examples of how organizations use the plan

Examples show practical outcomes when a standard Referral Action Plan is deployed across operations.

Martin Properties

Tim Martin streamlined lease-related referrals by standardizing the plan and capturing electronic signatures at intake.

Reduced turnaround time for tenant onboarding by minimizing document rework.
With standardized fields and secure signing, the team reported consistent compliance with document retention requirements and fewer delays in lease execution, improving operational predictability.

Fertility Centers of Illinois

John Butler used an electronic plan to attach medical authorizations and patient consents before specialist visits.

Ensured complete records were available at the first appointment.
The approach reduced administrative follow-up, maintained audit-ready records, and supported remote signing while preserving compliance controls required for sensitive health information.

Representative eSignature pricing and feature comparison

Compare base pricing and common capabilities for high-level vendor selection; consult each vendor for plan details and enterprise terms.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes	Yes	Yes	Yes	Yes
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

FAQs and troubleshooting for Referral Action Plans

Answers to common operational and legal questions about preparing, signing, and storing a Referral Action Plan.

Need help? Contact support

Can this document be signed electronically?
Yes. Under the federal ESIGN Act (15 U.S.C. ch. 96) and state UETA laws, electronic signatures are generally valid for most transactions, provided intent, consent, attribution, and retention are demonstrable.
When is a notary or witness required?
Notarization or witness requirements depend on state law and the document's purpose. Some states require witnesses for certain instruments; rely on state rules or counsel for transactions needing notarization or self-proving affidavits.
Are remote online notarizations allowed?
Many states permit RON with identity proofing and audio-video recording, but rules vary. Check the state notary commission or NCSL guidance before using RON for required acknowledgements.
How do I correct or amend a submitted plan?
Create a dated amendment or superseding plan that references the original, obtain required signatures, and retain both versions to preserve auditability and show change history.
Who should keep the master record?
The primary clinical or administrative record system should retain the master signed copy; additional copies may be stored in secure archives with access controls and retention consistent with policy.
What if a signer disputes the signature?
Preserve the audit trail (timestamps, IP, authentication method), any identity verification records, and related communications; these items support attribution and help resolve disputes.

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