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Free Alabama Medicaid Referral PDF Template

The Alabama Medicaid Referral Form (Form 362) is a crucial document used to facilitate the referral process for Medicaid recipients. This form captures essential information about the patient, primary physician, and the specific nature of the referral. Understanding how to complete this form accurately is vital for ensuring timely and effective medical care; to get started, fill out the form by clicking the button below.

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Outline

The Alabama Medicaid Referral Form, also known as Form 362, plays a crucial role in ensuring that patients receive the appropriate medical care they need. This form is designed to facilitate communication between primary care physicians and specialists, streamlining the referral process for Medicaid recipients. Key components include recipient information, such as the patient's name, Medicaid number, and contact details, which must be accurately filled out to avoid delays. The primary physician's details are also essential; their printed name and original signature are required for hard copy submissions, while electronic referrals necessitate a standardized electronic signature. Various types of referrals can be indicated on the form, including those for Patient 1st recipients, EPSDT screenings, and case management services. Furthermore, the form specifies the length of the referral and outlines whether the consultant is authorized to evaluate, treat, or refer the patient to another specialist. It also requires the primary physician to indicate the reason for the referral and any additional diagnoses identified during the initial examination. By ensuring that all these elements are correctly completed, healthcare providers can help patients navigate the complexities of Medicaid services more effectively.

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Documents used along the form

The Alabama Medicaid Referral Form is an essential document used in the process of referring patients for specialized care. However, it is often accompanied by several other forms and documents that facilitate the referral process and ensure comprehensive patient care. Below is a list of these documents, each serving a unique purpose in the healthcare system.

Patient Information Form: This form collects detailed demographic information about the patient, including contact details and insurance information. It is crucial for establishing the patient's identity and ensuring accurate billing.
Authorization for Release of Information: This document allows healthcare providers to share the patient's medical records with other professionals involved in their care. It is vital for maintaining continuity of care and ensuring that all providers have access to necessary information.
EPSDT Screening Report: The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) report documents the findings from the screening. It is used to determine if further evaluation or treatment is needed based on the child's health status.
Consultant Report: After a specialist evaluates the patient, this report details the findings, diagnosis, and recommended treatment. It is submitted to the primary physician to inform ongoing care decisions.
Case Management Plan: This document outlines the strategies and services necessary for managing a patient’s care, particularly for those with complex health needs. It ensures that all aspects of a patient’s health are addressed.
Power of Attorney for a Child Form: To ensure necessary decisions can be made in your absence, utilize the comprehensive Power of Attorney for a Child form resources that provide essential legal authority for child care arrangements.
Medicaid Provider Enrollment Form: This form is required for healthcare providers to enroll in the Medicaid program. It includes information about the provider's qualifications and services offered, ensuring compliance with Medicaid standards.
Billing and Claims Submission Form: After services are rendered, this form is used to submit claims for reimbursement to Medicaid. It includes details about the services provided, the provider, and the patient.
Follow-Up Care Instructions: This document provides guidance on the next steps in the patient’s care, including any recommended follow-up appointments or treatments. It is essential for ensuring that patients receive ongoing care as needed.

These documents collectively enhance the referral process, ensuring that patients receive timely and appropriate care while maintaining a clear line of communication among healthcare providers. Understanding each form's role can improve patient outcomes and streamline administrative tasks within the healthcare system.

Steps to Filling Out Alabama Medicaid Referral

Completing the Alabama Medicaid Referral form is an essential step in ensuring that patients receive the appropriate care and referrals they need. After filling out the form, it should be submitted to the relevant parties for processing. Here are the steps to fill out the form accurately:

Today’s Date: Write the date you are completing the form.
Referral Date: Indicate the date when the referral becomes effective.
Recipient Information: Fill in the patient’s name, Medicaid number, date of birth, address, telephone number, and the name of the parent or guardian.
Primary Physician Information: Provide all necessary details about the primary care physician, including their printed name and original signature. If submitting electronically, follow the electronic signature protocol.
Screening Provider: If different from the primary physician, the screening provider must complete and sign this section, especially if the referral is due to an EPSDT screening.
NPI Information: Enter the NPI number and, if available, the Medicaid Provider number for billing purposes.
Type of Referral: Select the appropriate type of referral from the options provided, such as Patient 1st, EPSDT, or Lock-In.
Length of Referral: Specify the number of visits or the duration for which the referral is valid. This is required for the referral to be considered valid.
Referral Valid For: Choose one of the options regarding the scope of the referral, such as evaluation only or treatment only.
Reason for Referral: Clearly indicate the reason or condition for which the recipient is being referred by the primary physician.
Other Conditions: Note any additional conditions or diagnoses identified by the primary physician during the initial examination.
Consultant Information: Fill in the consultant’s name, address, and telephone number.
Submission of Findings: Indicate how the primary physician wishes to receive the consultant's findings and treatment reports.

Misconceptions

Understanding the Alabama Medicaid Referral Form is crucial for both healthcare providers and recipients. However, several misconceptions can lead to confusion. Here are four common misconceptions about the form:

Misconception 1: Only primary physicians can complete the referral form.

This is not true. While the primary physician must provide their information and signature, a screening provider can also complete and sign the form if the referral arises from an EPSDT screening.

Misconception 2: Stamped signatures are acceptable on the referral form.

In fact, stamped or copied signatures are not accepted. An original signature from the primary care physician or their designee is required for hard copy referrals, ensuring authenticity and accountability.

Misconception 3: The referral is valid indefinitely.

This is incorrect. The form requires a specific length of referral, indicating the number of visits or duration for which the referral is valid. Without this information, the referral may not be honored.

Misconception 4: All referrals are for treatment only.

The referral form allows for various types of referrals, including evaluation only, treatment only, or a combination of both. It is important to select the appropriate type based on the patient's needs.

Form Sample

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

2-23-12

ALABAMA MEDICAID REFERRAL FORM

Today’s Date _________________

PHI-CONFIDENTIAL

Date Referral Begins _________________

Important NPI Information

(If different from above)

MEDICAID RECIPIENT INFORMATION

See Instructions

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

Address

Telephone # with Area Code

Fax # with Area Code

NPI #

Medicaid Provider #

Signature

TYPE OF REFERRAL

 Patient 1st

 Lock-in

 EPSDT

Screening Date ______________________

 Other

 Case Management/Care Coordination

LENGTH OF REFERRAL

Referral Valid for __________ month(s) or __________ visit(s) from date referral begins.

REFERRAL VALID FOR

 Evaluation Only

 Treatment Only

 Evaluation and Treatment

 Hospital Care (Outpatient)

 Referral by consultant to other provider for identified

 Performance of Interperiodic Screening (if necessary)

condition (cascading referral)

Referral by consultant to other provider for additional conditions diagnosed by consultant (EPSDT Only)

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. 2-23-12	www.medicaid.alabama.gov