Alabama Medicaid Form 362 Details

Alabama Medicaid is a government-sponsored healthcare program for residents who meet specific eligibility requirements. The program covers a variety of medical services, including doctor visits, prescription drugs, and hospital stays. If you think you may be eligible for Alabama Medicaid, it's important to learn about the referral process and how to apply. This article will provide an overview of the Alabama Medicaid referral process and help you determine if you are eligible for coverage.

This general report will help you figure out just how long it'll take you to complete alabama medicaid referral, how many pages it has, and a few additional unique specifics of the PDF.

QuestionAnswer
Form NameAlabama Medicaid Referral
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesalabama medicaid referral form 2017 fillable, alabama medicaid patient first referral form, medicaid form 362, alabama medicaid referral form

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

 

Instructions for Completing

 

TheAlabama MedicaidAgency Referral Form (Form 362)

TODAYS 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. Must have a signed, stamped or electronic signature

 

by primary physician (PMP) or designee.

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 that 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.

*”The Alabama Medicaid Provider Manual” is available on the Alabama Medicaid website

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.

Form 362

Alabama Medicaid Agency

Rev.7-30-10

www.medicaid.alabama.gov

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