Form 362 - Alabama Medicaid Referral Form Page 2

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Instructions for Completing
The Alabama Medicaid Agency Referral Form (Form 362)
T
’
D
:
Date form completed
ODAY
S
ATE
R
D
:
Date referral becomes effective
EFERRAL
ATE
R
I
:
Patient’s name, Medicaid number, date of birth, address, telephone number
ECIPIENT
NFORMATION
and parent’s/guardian’s name
P
P
:*
Provide all PMP information. Must have a signed, stamped or electronic signature
RIMARY
HYSICIAN
by primary physician (PMP) or designee.
S
P
:*
Screening provider (if different from primary physician) must complete and sign if the
CREENING
ROVIDER
referral is the result of an EPSDT screening
*
NPI I
:
Provide NPI number. For billing purposes indicate Medicaid Provider number, if available.
NFORMATION
T
R
:
YPE OF
EFERRAL
◆ Patient 1st - Referral to consultant for Patient 1st recipient only (See *Chapter 39 for Claim Filing Instructions).
◆ EPSDT - Referral resulting from an EPSDT screening of a child not in the Patient 1st
program – indicate screening date (See *Appendix A for Claim Filing Instructions).
◆ Case Management/Care Coordination - Referral for case management services through Patient 1st
Care Coordinators (See *Chapter 39 for Claim Filing Instructions).
◆ Lock-In - Referral for recipients on lock-in status who are locked in to one doctor and/or one pharmacy
(See *Chapter 3 -3.3.2 for Claim Filing Instructions).
◆ Patient 1st/EPSDT - Referral is a result of an EPSDT screening of a child that is in the Patient 1st
program – indicate screening date (See *Appendix A for Claim Filing Instructions).
◆ Other - For recipients who are not in Patient 1st program.
*”The Alabama Medicaid Provider Manual” is available on the Alabama Medicaid website
: : : : : Indicate the number of visits/length of time for which the referral is valid.
L
R
ENGTH OF
EFERRAL
Note: Must be completed for the referral to be valid.
R
V
F
:
EFERRAL
ALID
OR
◆ Evaluation Only - Consultant will evaluate and provide findings to Primary Physician (PMP).
◆ Evaluation and Treatment - Consultant can evaluate and treat for diagnosis listed on the referral.
◆ Referral By Consultant to Other Provider For Identified Condition (Cascading Referral) – After evaluation,
consultant may, using Primary Physician’s (PMP) provider number, refer recipient to another specialist as
indicated for the condition identified on the referral form.
◆ Referral By Consultant To Other Provider For Additional Conditions Diagnosed By Consultant (Cascading
Referral) – Consultant may refer recipient to another specialist for other diagnosed conditions without having
to get an additional referral from the Primary Physician (PMP).
◆ Treatment Only - Consultant will treat for diagnosis listed on referral.
◆ Hospital Care (Outpatient) - Consultant may provide care in an outpatient setting.
◆ Performance of Interperiodic Screening (if necessary) - Consultant may perform an interperiodic screening
if a condition was diagnosed that will require continued care or future follow-up visits.
R
F
R
B
P
P
(PMP): Indicate the reason/condition the recipient is being referred.
EASON
OR
EFERRAL
Y
RIMARY
HYSICIAN
O
C
/D
I
B
P
P
: Indicate any condition present at the time of initial
THER
ONDITIONS
IAGNOSIS
DENTIFIED
Y
RIMARY
HYSICIAN
exam by PMP.
C
I
: Consultant’s name, address and telephone number.
ONSULTANT
NFORMATION
P
S
F
P
P
B
: The Primary Physician (PMP)should indicate how he/she wants to be
LEASE
UBMIT
INDINGS TO
RIMARY
HYSICIAN
Y
notified by the consultant of findings and/or treatment rendered.
Form 362
Alabama Medicaid Agency
Rev.7-30-10

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