Alabama Medicaid Referral – Fill Out and Use This PDF

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