Healthy Connections Referral Form – Fill Out and Use This PDF

The Healthy Connections Referral Form is a crucial document for Medicaid participants requiring specialized medical services not directly provided by their primary care provider (PCP). It encompasses essential participant information, Medicaid provider and referral information, and specific service requests ranging from mental health to substance abuse treatment, among others. By ensuring that the form is accurately filled out and submitted, Medicaid participants can facilitate a smooth referral process to receive necessary specialized care.

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Healthy Connections Referral Form PDF Details

Ensuring timely and appropriate medical care for Medicaid participants is vital. The Healthy Connections Referral Form plays a crucial role in this process, bridging the gap between primary care providers (PCPs) and specialized medical services. This meticulously designed form captures essential Medicaid Participant Information, including the patient’s name, Medicaid ID, date of birth, and specifics about the appointment. It ventures further to encompass Medicaid Provider & Referral information, detailing the length of the referral—from a single visit up to a maximum of 12 months—and method of referral transmission, whether mailed or faxed. Important, too, is the inclusion of the specialist/provider's contact details and the type of service requested, which can range from mental health and substance abuse treatment to surgery and durable medical equipment needs. Notably, the form facilitates a streamlined communication line back to the PCP, mandating that specialists and providers share assessments and recommendations, vital for continuous patient care. For referrals surpassing the authorized services, re-initiating contact with the PCP is a procedural step indicated on the form. Additional components highlight services requiring a referral from the Healthy Connections PCP, contrasting with those services exempt from this requirement, illuminating the comprehensive nature of this instrumental form. Its strategic format and the detailed guidance it provides underscore its significance in the coordinated care ecosystem, ensuring Medicaid participants receive the necessary care, tailored to their specific health needs.

Question	Answer
Form Name	Healthy Connections Referral Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	59
Avg. time to fill out	12 min 22 sec
Other names	hw0231, healthy connections idaho, child and family connections referral form, children and family connection referral form

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	Healthy Connections Referral Form

Medicaid Participant Information
Patient Name:				Date:

Medicaid ID #:				DOB:

Appointment (Day/Date):

Medicaid Provider & Referral Information
Length of Referral: 1 Visit		Visits	3 Months	6 Months 12 Months	Other:

(maximum length of referral not to exceed 12 months – referrals for ongoing services must be renewed at least annually)

Referral Mailed

Referral Faxed

Name of Specialist/Provider:

Address:

Phone Number:

Or, Referral for the following diagnosis/problem:

Remarks:

Authorize specialist/provider to pass on this referral to Medicaid providers for services specific to this diagnosis/treatment (e.g. hospital, physical therapy, and durable medical equipment)

Type of Service Requested	Mental Health (MH) Services (Adult and Children)
Evaluate & Recommend Treatment	Psychosocial Rehabilitation	Case Management
Diagnose & Treat	MH Clinic Services	Substance Abuse Treatment

Follow patient jointly	Assessment, Evaluation and/or Plan Development
Assume care of patient	Assessment, Evaluation and/or Plan Development
Assume care of patient
Surgery, if needed	Other:
Surgery, if needed
Durable Medical Equipment (description):	Developmental Disability (DD) Services (Adults and Children)


One visit referral for this service, no further	Developmental Therapy	Speech Therapy
Referrals issued until patient is seen by the	Physical Therapy	Occupational Therapy
Healthy Connections (HC) primary care provider	Physical Therapy	Occupational Therapy
Healthy Connections (HC) primary care provider	Service Coordination	Intense Behavioral Intervention (IBI)
(PCP)	Service Coordination	Intense Behavioral Intervention (IBI)
(PCP)
	Assessment, Evaluation and/or Plan Development
Other:	Assessment, Evaluation and/or Plan Development

	Other:
	Other:

Please Send Written Report

Please Phone With Report

Please Fax Report

HC Provider Referral Number:

PCP Signature:

PCP: (Typed, printed or stamped)	Name:
	Mailing Address:
	Phone:
	Fax:

For questions regarding this referral please ask for:

Notes to specialists/providers: • In all cases, communicate your assessment and recommendations back to the PCP

•If services beyond those authorized are needed, contact the PCP

See Reverse Side Regarding: • Medicaid covered services which require a referral

•Medicaid covered services which do not require a referral

•Changes to original referral must be authorized by Primary Care Provider

(HW0231 Rev. 03/12/2009)

The following services require a referral from the Healthy Connections Primary Care Provider (PCP)

•	Ambulatory Surgical Center Services		•	Oxygen and Related Services
•	Case Management		•	Physician Services: Not provided by the Healthy Connections
•	Developmental Therapy			(HC) PCP. Including any pre-operative exams for surgical
				services.
•
	Durable Medical Equipment and Supplies (DME)		•	Physical Therapy
•
	Home Health Service		• Prosthetic and Orthotic Services
•
	Hospice Services		•	Psychosocial Rehabilitation Services
•
	Hospital Services: Inpatient and outpatient	services.	•	Service Coordination
	(Some inpatient stays require PA through Qualis Health)
			•
•	Intensive Behavioral Intervention (IBI)			Speech Therapy
			• Substance Abuse Treatment Services
•	Mental Health Clinic Services
			•
•	Occupational Therapy			Urgent Care Centers

Note: Some services require a prior authorization (PA) from the Department and a referral from the Healthy Connections PCP. For more information regarding Healthy Connections referral requirements, please refer to your Idaho Medicaid Provider Handbook.

The following services do not require a referral from the Healthy Connections Primary Care Provider (PCP)

•	Anesthesiology	•	Long-Term Care Facilities: Nursing Facilities and
•	Audiology Services (Performed in the office of a certified		intermediate care facility requires authorization from the
•	Audiology Services (Performed in the office of a certified		department.
	audiologist)		department.
	audiologist)	• Personal Care Services: Requires PA from the
•	Chiropractic Services (Performed in the office) Medicaid	• Personal Care Services: Requires PA from the
•	Chiropractic Services (Performed in the office) Medicaid		department.
	does not reimburse chiropractors for x-rays.		department.
	does not reimburse chiropractors for x-rays.	• Personal Care Service Coordination: Requires PA
•	Dental Services	• Personal Care Service Coordination: Requires PA
•	Dental Services		from the department.
•			from the department.
•	Emergency Services (Performed in an	• Pharmacy Services: For prescription drugs only.
	emergency department of a hospital)	• Pharmacy Services: For prescription drugs only.
	emergency department of a hospital)		DME provided by pharmacies such as infusion
•			DME provided by pharmacies such as infusion
•	Family Planning Services: Counseling and		pumps will require a referral and may require a PA
	supplies to prevent pregnancy.		from the department.
•	Home and Community Bases Services (Waiver):	•	Podiatry Services: Performed in the office. Services
	Requires PA from the department.		provided outside the Podiatrist’s office (hospital or ambulatory
•	Immunizations: Only when vaccine(s) is billed alone or in		surgery center) will require a referral from the PCP.
•	Immunizations: Only when vaccine(s) is billed alone or in	•
	conjunction with an administration fee. Specialty	•	Radiological Services.
	physicians/providers administering immunizations are	• School-based Services: Medicaid-covered medical
	asked to provide the participant's PCP with immunization	• School-based Services: Medicaid-covered medical
	asked to provide the participant's PCP with immunization		services delivered by a school district or the
	records to assure continuity of care and avoid duplication		services delivered by a school district or the
	records to assure continuity of care and avoid duplication		Infant/Toddler Program.
	of services.		Infant/Toddler Program.
	of services.	• Screening Mammographies: Limited to one per
•	Indian Health Clinic Services	• Screening Mammographies: Limited to one per
•	Indian Health Clinic Services		calendar year for women age 40 or older.
•			calendar year for women age 40 or older.
•	Influenza Shots Pneumococcal Vaccine: Only when	• Sexually Transmitted Disease: Diagnosis and/or treatment.
	vaccine is billed alone or in conjunction with an	• Sexually Transmitted Disease: Diagnosis and/or treatment.
	vaccine is billed alone or in conjunction with an	•
	administration fee.	•	Vision Services: Performed in the offices of
•	Laboratory and Pathology Services		ophthalmologists and optometrists, including eye
•	Laboratory and Pathology Services		glasses. This does not include services performed in
			glasses. This does not include services performed in
			a hospital or ambulatory surgery

For more information on Idaho Medicaid requirements, please refer to your Idaho Medicaid Provider Handbook.

(HW0231 Rev. 03/12/2009)

Healthy Connections Referral Form – Fill Out and Use This PDF

Healthy Connections Referral Form PDF Details

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