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.

Form NameHealthy Connections Referral Form
Form Length2 pages
Fillable fields59
Avg. time to fill out12 min 22 sec
Other nameshw0231, healthy connections idaho, child and family connections referral form, children and family connection referral form

Form Preview Example



Healthy Connections Referral Form














Medicaid Participant Information









Patient Name:


















Medicaid ID #:


















Appointment (Day/Date):

















Medicaid Provider & Referral Information







Length of Referral: 1 Visit



3 Months

6 Months 12 Months











(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:


Phone Number:

Or, Referral for the following diagnosis/problem:


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










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






Service Coordination

Intense Behavioral Intervention (IBI)

















Assessment, Evaluation and/or Plan Development




















































Please Send Written Report

Please Phone With Report

Please Fax Report

HC Provider Referral Number:

PCP Signature:

PCP: (Typed, printed or stamped)



Mailing Address:





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







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


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)


Long-Term Care Facilities: Nursing Facilities and

Audiology Services (Performed in the office of a certified


intermediate care facility requires authorization from the







Personal Care Services: Requires PA from the

Chiropractic Services (Performed in the office) Medicaid




does not reimburse chiropractors for x-rays.



Personal Care Service Coordination: Requires PA

Dental Services


from the department.



Emergency Services (Performed in an

Pharmacy Services: For prescription drugs only.


emergency department of a hospital)



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.



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



services delivered by a school district or the


records to assure continuity of care and avoid duplication




Infant/Toddler Program.


of services.



Screening Mammographies: Limited to one per

Indian Health Clinic Services


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




administration fee.

Vision Services: Performed in the offices of

Laboratory and Pathology Services


ophthalmologists and optometrists, including eye


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)