Alabama Form 362 PDF Details

Understanding the Alabama 362 form is crucial for anyone involved with Medicaid services in the state of Alabama. This special form plays a pivotal role by serving as a Medicaid Referral Form, essential for facilitating various medical services for Medicaid recipients. The document captures critical information, including the patient's personal details, the referring and receiving healthcare providers' details, and the type of referral being made—details that ensure Medicaid recipients receive the proper care and services they need. Types of referrals range from Patient 1st to EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) screenings and others, including case management and care coordination. The form must specify the referral's length, showcasing its validity in terms of months or visits, and detail the extent of the referral, whether for evaluation, treatment, or both. Additionally, when specialists are involved, it channels the flow of important medical information back to the primary care provider, highlighting a structured and coordinated approach to Medicaid recipient care. This documentation, updated by the Alabama Medicaid Agency, is not only a formality but a vital tool in maintaining the health and well-being of Medicaid beneficiaries, marking a critical step in ensuring that referrals are processed efficiently and accurately.

QuestionAnswer
Form NameAlabama Form 362
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesfillable form 362 alabama medicaid referral, alabama medicaid fillable online forms 234, alabama medicaid referral form form 362, medicaid form 362

Form Preview Example

ALABAMA MEDICAID REFERRAL FORM

Today’s Date _________________

PHI-CONFIDENTIAL

ImportantNPIInformation

See Instructions

Date Referral Begins _________________

MEDICAID RECIPIENT INFORMATION

Recipient Name

Recipient #

Recipient DOB

Address

Telephone # with Area Code

 

 

 

 

 

 

 

 

 

Name of Parent/Guardian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRIMARY PHYSICIAN (PMP) INFORMATION

SCREENING PROVIDER IF DIFFERENT FROM PRIMARY PHYSICIAN (PMP)

Name

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone # with Area Code

 

 

Telephone # with Area Code

 

 

Fax # with Area Code

 

 

Fax # with Area Code

 

 

 

 

 

 

 

Email

 

 

 

 

 

 

Email

 

 

 

 

 

 

 

NPI #

 

 

 

 

 

 

NPI #

 

 

 

 

 

 

 

Medicaid Provider #

Medicaid Provider #

 

 

 

 

 

 

Signature

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF REFERRAL

 

 

 

 

 

 

 

 

 

 

 

 

❑

Patient 1st

 

 

 

 

 

❑

Lock-in

 

 

 

 

 

 

❑

EPSDT

Screening Date ______________________

❑

Patient 1st/EPSDT

Screening Date ____________________

❑

Case Management/Care Coordination

❑

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LENGTH OF REFERRAL

Referral Valid for __________ month(s) or __________ visit(s) from date referral begins.

REFERRAL VALID FOR

❑Evaluation Only

❑Evaluation and Treatment

❑Referral by consultant to other provider for identified condition (cascading referral)

❑Referral by consultant to other provider for additional conditions diagnosed by consultant (cascading referral)

❑Treatment Only

❑Hospital Care (Outpatient)

❑Performance of Interperiodic Screening (if necessary)

Reason for referral by PMP

Other conditions/diagnoses identified by PMP

CONSULTANT INFORMATION

Consultant Name

Address

Consultant Telephone # with Area Code

Note: Please submit written report of findings including the date of examination/service, diagnosis, and consultant signature to Primary Physician (PMP).

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

www.medicaid.alabama.gov

How to Edit Alabama Form 362 Online for Free

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This document will need specific data to be filled out, therefore be sure to take whatever time to provide exactly what is expected:

1. The fillable form 362 alabama medicaid referral needs specific information to be typed in. Ensure that the following blank fields are completed:

Ways to fill out alabama medicaid form 362 part 1

2. The subsequent step is usually to submit these particular fields: NPI , Medicaid Provider , Signature, TYPE OF REFERRAL, NPI , Medicaid Provider , Signature, Patient st EPSDT Screening Date , Lockin Patient stEPSDT Screening, LENGTH OF REFERRAL, Referral Valid for months or , REFERRAL VALID FOR, Evaluation Only Evaluation and, condition cascading referral, and Referral by consultant to other.

Step # 2 of filling in alabama medicaid form 362

3. This next step is focused on CONSULTANT INFORMATION, Consultant Name, Address, Consultant Telephone with Area, Note Please submit written report, Findings should be submitted to, Mail, Form Rev , Email, Fax, In addition please telephone, and Alabama Medicaid Agency - complete all these blank fields.

Part no. 3 for filling in alabama medicaid form 362

As to In addition please telephone and CONSULTANT INFORMATION, be sure that you double-check them here. Both of these are certainly the key ones in this document.

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