Form 362: Alabama Medicaid Referral Form

Form 362 Alabama Medicaid Agency Revised 6/2023 www.medicaid.alabama.gov Instructions for Completing The Alabama Medicaid Referral Form (Form 362) TODAY'S DATE: Enter the date the form is completed.

Enter the date the referral becomes effective.

RECIPIENT INFORMATION: Enter the patient's name, Medicaid number, date of birth, address, telephone number and parent's/guardian's name.

Enter the name, NPI, Medicaid Provider ID#, address, email, telephone number, and fax number of the screening provider.

Stamped or copied signatures will not be accepted.

For electronic referrals provider certification is made via standardized electronic signature protocol.

TYPE OF REFERRAL: Check the box beside the type of referral being made.  Case Management/Care Coordination - Referral for case management services through Network Care Coordinators (See *Chapter 40 for ACHN contact information).  EPSDT - Referral resulting from an EPSDT screening - indicate screening date (See *Appendix A for Claim Filing Instructions).

Periodic: Well-child checkups that are based on a periodicity schedule. Interperiodic: Problem-focused and abnormal screenings that are medically necessary for undiagnosed conditions outside the periodicity schedule.  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).  Other - All other referral types (Describe referral type).

Indicate the number of visits or length of time for which the referral is valid.

(Note: Must be completed for the referral to be valid).

REFERRAL VALID FOR: Indicate the reason or condition for which the recipient is being referred.  Evaluation Only - Consultant will evaluate and provide findings to.  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 NPI, refer recipient to another specialist as indicated for the condition identified on the referral form without having to get an additional referral from the screening provider.  Referral by consultant to another 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 screening provider (EPSDT ONLY).  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.  For Billing Purposes Only:  Other - All other referral validation types (i.e., DME).

OTHER CONDITIONS/DIAGNOSIS IDENTIFIED BY - Indicate any condition present at the time of initial exam by.

Enter the consultant's name, address, and telephone number.

The consultant can be an individual provider or provider group.

The screening provider should indicate how he/she wants to be notified by the consultant of findings and/or treatment rendered.

Form 362 is the Alabama Medicaid Referral Form of the Alabama Medicaid Agency. The screening provider must complete and sign the referral form if an EPSDT screening results in the recipient's referral to another provider.