Form Pi 118 - Medical Referral Form Of Restricted Participants - Missouri Department Of Social Services

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J
W. (J
) N
, G
• B
K
, D
EREMIAH
AY
IXON
OVERNOR
RIAN
INKADE
IRECTOR
M
&
ISSOURI MEDICAID AUDIT
COMPLIANCE UNIT
6500 • J
P.O. B
C
, MO 65102-6500
OX
EFFERSON
ITY
• 573-751-3399
.
.
.
WWW
DSS
MO
GOV
Missouri Medicaid Audit & Compliance Unit
MEDICAL REFERRAL FORM OF RESTRICTED PARTICIPANTS
PARTICIPANT NAME:___________________________________________________________________________
(Last)
(First)
(Middle)
PARTICIPANT IDENTIFICATION NUMBER:__________________________________________________________
AUTHORIZED PROVIDER MAKING REFERRAL:_______________________________________________________
PROVIDER VENDOR NUMBER:___________________________________________________________________
TAXONOMY CODE :___________________________________________________________________________
(If applicable)
AUTHORIZED PROVIDER’S SIGNATURE:__________________________________________________________
DATE OF SIGNATURE:________________________________________________________________________
DATE OF SERVICE:__________________________________________________________________________
REASON FOR REFERRAL:_____________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
REFERRING TO:____________________________________________________________________________
(Provider’s Name)
ADDRESS:___________________________________________________ PHONE: __________________
PROVIDER VENDOR NUMBER:_________________________________________________________________
TAXONOMY CODE :_________________________________________________________________________
(If applicable)
This form is to be completed and signed by the authorized lock-in provider when a referral to another provider is
medically necessary.
This referral form should NOT be attached to the claim form.
You may either send it to Infocrossing
Healthcare Services, Inc., P.O. Box 5900, Jefferson City, MO 65102 or submit via Internet. The website for these
submissions is A referral form is needed for each claim in which services are rendered to a
Missouri restricted participant in order for the provider performing the service to receive payment for his or her
claim.
THIS REFERRAL IS GOOD ONLY FOR 30 DAYS FROM THE DATE OF SERVICE.
PI 118 - Revised 02/15
Interpretive services are available by calling the Participant Services Unit at 1-800-392-2161.
Prevodilačke usluge su dostupne pozivom odjela koji učestvuje u ovom servisu na broj 1-800-392-2161.
Servicios Intreprative están disponibles llamando a la unidad de servicios de los participantes al 1-800-392-2161.
R
M
ELAY
ISSOURI
1-800-735-2466 VOICE • 1-800-735-2966
FOR HEARING AND SPEECH IMPAIRED
TEXT PHONE
An Equal Opportunity Employer, services provided on a nondiscriminatory basis.

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