Form 362 - Alabama Medicaid Referral Form

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REQUIRED FIELDS IN RED
A
M
R
F
LABAMA
EDICAID
EFERRAL
ORM
REQUIRED
REQUIRED
PHI-CONFIDENTIAL
Today’s Date _________________
Date Referral Begins _________________
Important NPI Information
See Instructions
M
R
I
EDICAID
ECIPIENT
NFORMATION
Recipient Name
Recipient #
Recipient DOB
REQUIRED
REQUIRED
REQUIRED
Address
Telephone # with Area Code
Name of Parent/Guardian
P
P
(PMP) I
S
P
I
D
F
P
P
(PMP)
RIMARY
HYSICIAN
NFORMATION
CREENING
ROVIDER
F
IFFERENT
ROM
RIMARY
HYSICIAN
Name
Name
REQUIRED
REQUIRED (FOR EPSDT)
Address
Address
REQUIRED
REQUIRED (FOR EPSDT)
Telephone # with Area Code
Telephone # with Area Code
Fax # with Area Code
Fax # with Area Code
Email
Email
REQUIRED (FOR EPSDT)
REQUIRED
NPI #
NPI #
Medicaid Provider #
Medicaid Provider #
)
REQUIRED (SEE APPENDIX A)
REQUIRED (FOR EPSDT) (SEE APPENDIX A
Signature
Signature
REQUIRED
T
R
YPE OF
EFERRAL
❑ Patient 1
❑ Lock-in
st
REQUIRED (FOR EPSDT)
REQUIRED (FOR EPSDT)
❑ EPSDT
❑ Patient 1
Screening Date ______________________
st
/EPSDT
Screening Date ____________________
❑ Case Management/Care Coordination
❑ Other
L
R
ENGTH OF
EFERRAL
REQUIRED
REQUIRED
UP TO 12 MONTHS FROM SCREENING DATE
Referral Valid for __________ month(s) or __________ visit(s) from date referral begins.
REQUIRED
R
V
F
EFERRAL
ALID
OR
❑ Evaluation Only
❑ Treatment Only
❑ Evaluation and Treatment
❑ Hospital Care (Outpatient)
❑ Referral by consultant to other provider for identified
❑ Performance of Interperiodic Screening (if necessary)
condition (cascading referral)
❑ Referral by consultant to other provider for additional
conditions diagnosed by consultant (cascading referral)
Reason for referral by PMP
Other conditions/diagnoses identified by PMP
REQUIRED
C
I
ONSULTANT
NFORMATION
REQUIRED
Consultant Name
Address
Consultant Telephone # with Area Code
(PMP)
Note: Please submit written report of findings including the date of examination/service, diagnosis, and consultant signature to Primary Physician
.
Findings should be submitted to primary physician (PMP) by
❑ Mail
❑ E-mail
❑ Fax
❑ In addition, please telephone
Form 362
Alabama Medicaid Agency
Rev. 7-30-10

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