Alabama Medicaid Referral PDF Details

The Alabama Medicaid Referral Form (Form 362) serves as a crucial tool for healthcare providers within the state's Medicaid system, ensuring that recipients obtain the necessary specialist consultations, screenings, and treatments in a streamlined and coordinated manner. Updated on February 23, 2012, the form mandates comprehensive recipient information, including personal and Medicaid identification details, alongside the primary physician’s (primary medical provider or PMP) data, underscored by the necessity of an original signature to validate hard copy referrals, or a standardized electronic signature for digital submissions. The form delineates various referral types—ranging from Patient 1st specific consultations to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) screenings, case management services, lock-in program directives, and more expansive health needs—not in the Patient 1st program. It establishes the referral's scope, from evaluation only, treatment, or both, to interperiodic screenings for ongoing conditions, specifying the length and validity of the referral. Additionally, the form includes a section for the consultant to report back to the Primary Physician with findings, creating a closed-loop communication channel to ensure continuous and coordinated patient care. Such detailed procedural guidance, provided by the form, exemplifies Alabama Medicaid's committed approach to managing patient referrals within its network, supporting efficient, timely, and appropriate healthcare service delivery. The official resource for more in-depth information on the form and related procedures is the Alabama Medicaid website, directly facilitating access to the provider manual and further administrative documents.

QuestionAnswer
Form NameAlabama Medicaid Referral
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesal medicaid referral form, medicaid referral form 362, medicaid alabama referral form, medicaid referral form alabama

Form Preview Example

2/23/12

Instructions for Completing

The Alabama Medicaid Agency Referral Form (Form 362)

TODAY’S DATE: Date form completed

REFERRAL DATE: Date referral becomes effective

RECIPIENT INFORMATION:

Patient’s name, Medicaid number, date of birth, address, telephone number and parent’s/guardian’s name

PRIMARY PHYSICIAN:* Provide all PMP information. For hard copy referrals, the printed, typed, or stamped name of the primary care physicians with an original signature of the physician or designee is required. Stamped or copied signatures will not be accepted. For electronic referrals provider certification is made via standardized electronic signature protocol.

SCREENING PROVIDER:* Screening provider (if different from primary physician) must complete and sign if the referral is the result of an EPSDT screening.

*NPI INFORMATION: Provide NPI number. For billing purposes indicate Medicaid Provider number, if available.

TYPE OF REFERRAL:

◆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 who 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.

LENGTH OF REFERRAL: Indicate the number of visits/length of time for which the referral is valid.

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

REFERRAL VALID FOR:

◆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.

REASON FOR REFERRAL BY PRIMARY PHYSICIAN (PMP):

Indicate the reason/condition the recipient is being referred.

OTHER CONDITIONS/DIAGNOSIS IDENTIFIED BY PRIMARY PHYSICIAN:

Indicate any condition present at the time of initial exam by PMP.

CONSULTANT INFORMATION: Consultant’s name, address and telephone number.

PLEASE SUBMIT FINDINGS TO PRIMARY PHYSICIAN BY: The Primary Physician (PMP) should indicate how he/she wants to be notified by the consultant of findings and/or treatment rendered.

*The Alabama Medicaid Provider Manual is available on the Alabama Medicaid website| at http://www.medicaid.alabama.gov/CONTENT/6.0_Providers/6.7_Manuals.aspx

2-23-12

 

 

 

 

ALABAMA MEDICAID REFERRAL FORM

 

 

Today’s Date _________________

 

 

 

 

 

 

 

 

 

 

 

 

PHI-CONFIDENTIAL

Date Referral Begins _________________

 

 

 

 

 

Important NPI Information

 

 

 

 

 

 

(If different from above)

MEDICAID RECIPIENT INFORMATION

See Instructions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 ______________________

 

 

 

 

Other

 

 

 

 

 

 

 

 

Case Management/Care Coordination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LENGTH OF REFERRAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERRAL VALID FOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 (EPSDT Only)

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. 2-23-12

www.medicaid.alabama.gov

How to Edit Alabama Medicaid Referral Online for Free

We were designing the PDF editor with the concept of making it as effortless to apply as it can be. This is the reason the procedure of filling in the alabama medicaid referral form will be simple follow these particular steps:

Step 1: Hit the orange button "Get Form Here" on the following web page.

Step 2: At the moment, you can update your alabama medicaid referral form. This multifunctional toolbar makes it possible to include, delete, adapt, highlight, and also perform many other commands to the text and areas inside the file.

Provide the data requested by the program to create the document.

alabama medicaid referral form 2017 fillable empty spaces to complete

The system will need you to prepare the MEDICAID RECIPIENT INFORMATION, Address, ALABAMA MEDICAID REFERRAL FORM, Todays Date, Date Referral Begins, If different from above, Recipient, Recipient DOB, Telephone with Area Code, Name of ParentGuardian, PRIMARY PHYSICIAN PMP INFORMATION, SCREENING PROVIDER IF DIFFERENT, Name, Address, and Telephone with Area Code part.

stage 2 to completing alabama medicaid referral form 2017 fillable

The software will require you to note certain relevant info to instantly fill in the segment TYPE OF REFERRAL, Patient st EPSDT Screening Date, LENGTH OF REFERRAL, Lockin Other, Referral Valid for months or, REFERRAL VALID FOR, Evaluation Only Evaluation and, condition cascading referral, Referral by consultant to other, Treatment Only Hospital Care, Reason for referral by PMP, and Other conditionsdiagnoses.

alabama medicaid referral form 2017 fillable TYPE OF REFERRAL, Patient st EPSDT Screening Date, LENGTH OF REFERRAL, Lockin Other, Referral Valid for months or, REFERRAL VALID FOR, Evaluation Only Evaluation and, condition cascading referral, Referral by consultant to other, Treatment Only Hospital Care, Reason for referral by PMP, and Other conditionsdiagnoses blanks to complete

The 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 area will be the place to include the rights and responsibilities of both parties.

step 4 to finishing alabama medicaid referral form 2017 fillable

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