Healthy Connections Referral Form PDF Details

Are you looking for a way to connect with local health and wellness services? The Healthy Connections Referral Form is an invaluable resource that can help you locate programs and resources in your community. Whether you're seeking one-on-one counseling, group support, or just need someone to talk to – this comprehensive form makes finding the right type of care incredibly easy. Read on to learn more about how the Healthy Connections Referral Form can get you connected and on the road towards better mental health.

QuestionAnswer
Form NameHealthy Connections Referral Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesconnections referral form, healthy connections referral, child and family connections referral form, health connect referral form

Form Preview Example

 

 

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

 

 

 

 

 

 

 

 

 

Surgery, if needed

 

 

Other:

 

 

 

 

 

 

 

 

 

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)

 

(PCP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

department.

 

audiologist)

 

 

Personal Care Services: Requires PA from the

Chiropractic Services (Performed in the office) Medicaid

 

department.

 

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)