Fill in a Valid Alabama Medicaid Referral Template

The Alabama Medicaid Referral Form (Form 362) is a crucial document utilized in the Medicaid system to facilitate communication between primary care physicians and specialists. It includes essential patient details, referral specifics, and the necessary signatures to ensure compliance and proper care coordination. Understanding how to accurately complete this form can significantly impact the quality of medical services provided to Medicaid recipients, making it imperative for healthcare providers to be well-versed in its requirements.

To streamline the referral process, consider filling out the Alabama Medicaid Referral Form by clicking the button below.

Fill in a Valid Alabama Medicaid Referral Template

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The Alabama Medicaid Referral Form, also known as Form 362, plays a crucial role in ensuring continuity and quality of care for Medicaid recipients. This form facilitates communication between primary care physicians and specialists when a patient needs additional evaluations or treatments. Key components of the form include essential recipient information such as the patient's name, Medicaid number, date of birth, and contact details, which ensure accurate identification of the patient. Additionally, the form requires details about the primary physician, including their name, contact information, and a signature to authorize the referral. If applicable, a screening provider's information must also be included, particularly if the referral stems from an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) examination. Other significant sections outline the type of referral being made, whether it's for case management, lock-in status, or specialized treatment following diagnosed conditions. Furthermore, it is essential to specify the duration of the referral and the reasons behind it, along with any additional conditions identified during the primary physician's evaluation. Lastly, consultant information, including their name and contact details, is crucial for the smooth transfer of findings back to the primary physician, highlighting the collaborative nature of patient care under Alabama Medicaid.

Alabama Medicaid Referral Example

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

Click for Alabama Medicaid Referral File

File Breakdown

Fact Name	Description
Form Identification	This form is referred to as the Alabama Medicaid Referral Form (Form 362).
Effective Dates	Two specific dates must be included: today's date and the referral date when the referral becomes effective.
Recipient Information	Includes the patient’s name, Medicaid number, date of birth, address, telephone number, and parent or guardian's name.
Primary Physician Requirements	The primary physician must provide all pertinent information, including an original signature for hard copies; electronic signatures follow a specified protocol.
Types of Referrals	Referral types include Patient 1st, EPSDT, Case Management/Care Coordination, Lock-In, and others. Each type has specific guidelines outlined in relevant chapters and appendices.
Length of Referral	The form requires indication of how long the referral is valid, based on visits or months.
Consultant Information	Consultant details such as name, address, and telephone number, must be provided.
Governing Laws	This referral form complies with the Alabama Medicaid Provider Manual and relevant Alabama state laws regarding Medicaid referrals.

Guide to Using Alabama Medicaid Referral

Filling out the Alabama Medicaid Referral form is an essential step in ensuring appropriate medical care. Once completed, this form is sent to the relevant healthcare providers who will use the information to assist in treatment and to comply with Medicaid guidelines.

Enter Today's Date: Fill in the date you are completing the form.
Referral Date: Specify the date when the referral will take effect.
Provide Recipient Information: Include the patient's full name, Medicaid number, date of birth, address, telephone number, and the name of their parent or guardian.
Primary Physician Information: Provide all details of the Primary Medical Provider (PMP). Ensure that the printed, typed, or stamped name of the primary care physician is included, along with an original signature. Avoid using stamped or copied signatures.
Screening Provider Information (if applicable): If the screening provider differs from the primary physician, complete and sign this section.
Enter NPI Information: Provide the National Provider Identifier number. If available, add the Medicaid Provider number for billing purposes.
Select Type of Referral: Choose the appropriate type of referral from the provided options.
Length of Referral: Indicate the number of visits or the duration for which the referral is valid.
Referral Valid For: Specify what the consultant is authorized to do, such as “Evaluation Only” or “Treatment Only.”
Reason for Referral: Clearly state the reason or medical condition prompting the referral by the Primary Physician (PMP).
Other Conditions/Diagnosis: List any other diagnosis made by the Primary Physician at the time of the initial exam.
Consultant Information: Provide the consultant's name, address, and telephone number.
Submission Information: Indicate how the Primary Physician would like to receive the consultant's findings, such as by mail or email.

Get Answers on Alabama Medicaid Referral

What is the Alabama Medicaid Referral form?

The Alabama Medicaid Referral form, also known as Form 362, is used to document referrals of Medicaid recipients from primary physicians to specialists or other healthcare providers. This form ensures that all necessary information is included when a patient is referred for further evaluation or treatment.

Who needs to fill out the referral form?

The referral form is primarily completed by the primary care physician (PMP) who is treating the patient. If the referral arises from a screening, the screening provider must also fill in their information. Both providers must sign the form to confirm the referral.

What information is required on the form?

The form requires several key pieces of information:

Today's date and the referral date
Patient's details, such as name, Medicaid number, date of birth, address, and guardian's name
Primary physician information, including name, address, telephone number, and signature
Screening provider information if applicable
Type of referral (e.g., EPSDT, Case Management)
Length of the referral and its valid duration
Details about the consultant

How long is a referral valid?

The length of a referral can vary based on the information provided. It can be valid for a specific number of visits or a set number of months. The primary physician must clearly indicate the duration on the form for it to remain valid.

What types of referrals are available on the form?

The form includes several types of referrals, such as:

Patient 1st
EPSDT
Case Management/Care Coordination
Lock-In
Other

Each type serves different situations and should be selected based on the patient's needs.

What happens after the specialist evaluates the patient?

After the specialist evaluates the patient, they are required to submit a written report of their findings back to the primary physician. This report should include the examination date, diagnosis, and the specialist's signature. The primary physician should also specify how they would like to receive this information.

Can the consultant refer the patient to another provider?

Yes, the consultant may refer the patient to another provider if additional treatment is needed. This process, known as a cascading referral, does not require a new referral from the primary physician as long as the conditions are related to what was initially diagnosed.

How can I get more information or assistance regarding the referral form?

For more detailed guidance, you can visit the Alabama Medicaid website, where the Alabama Medicaid Provider Manual is available. This manual contains comprehensive instructions on completing the referral form and additional resources to help providers.

Common mistakes

Filling out the Alabama Medicaid Referral form correctly is crucial for ensuring timely medical care. One common mistake occurs when individuals fail to provide complete recipient information. Missing details such as the patient’s name, Medicaid number, or date of birth can delay the referral process. Each piece of information is necessary for proper identification and effective communication between healthcare providers.

Another frequent error is related to the primary physician’s information. It is vital to include all required information, including the physician's name and signature. Some people mistakenly provide stamped or copied signatures, which the Alabama Medicaid Agency does not accept. Using an original signature is mandatory, so always ensure the completeness of this section before submission.

The type of referral chosen is also often incorrect. Each referral type has specific criteria, and selecting the wrong option can cause significant delays. For instance, if a referral is the result of an EPSDT screening but is marked as “Patient 1st,” it could result in denials for necessary treatment. Take the time to read the options carefully and select the one that accurately reflects the situation.

Lastly, leaving the section regarding the length of the referral blank can invalidate the entire request. Whether the referral is for a specific number of visits or a set period, this detail is essential for compliance. Omitting this information can lead to confusion and further complications in accessing medical care. Always verify that this section contains the necessary information.

Documents used along the form

The Alabama Medicaid Referral form is a crucial document that facilitates communication between primary care physicians and specialists. Alongside this form, there are several other documents that are often used to ensure continuity and effectiveness of care for Medicaid recipients. Below are key forms that may accompany the referral process:

Alabama Medicaid Provider Manual: This manual provides detailed guidelines for providers on the various policies, procedures, and requirements for delivering Medicaid services. It serves as a comprehensive resource for understanding billing and service delivery protocols.
Patient Information Form: This form collects essential information about the recipient, including demographics, medical history, and current medications. It ensures that specialists have all necessary background when a patient is referred.
Authorization for Release of Information: This document permits healthcare providers to share patient information with other parties involved in the recipient's care. It is vital for maintaining the flow of information among providers.
EPSDT Screening Report: For patients eligible under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, this report details the regular screenings a child has undergone and any identified health issues that may require referrals.
Consultant Report: After a specialist sees the patient, this report summarizes findings, diagnoses, and recommended treatment plans. It is typically sent back to the primary physician for follow-up and ongoing care coordination.
Care Coordination Plan: This plan outlines the specific services a patient may need moving forward. It coordinates treatment among different healthcare providers involved in the patient’s care and sets clear goals for medical outcomes.

These documents enhance the referral process and help ensure that patients receive comprehensive and integrated care. Familiarity with these forms can streamline communication, improve patient outcomes, and support collaboration among healthcare providers.

Similar forms

Referral for Medical Services: Similar to the Alabama Medicaid Referral form, medical referral forms are used by healthcare providers to direct patients to specialists or secondary care services. Both documents contain essential patient information, the reason for referral, and specifics about the provider and treatment to ensure that the referred services are appropriate and timely.
Consultation Request Form: A consultation request form is akin to the Alabama Medicaid Referral form as it also seeks a specialist’s evaluation or treatment for a patient. It includes sections for both the referring physician and the consultant, detailing patient demographics and the purpose of the consultation.
Pre-Authorization Request: Pre-authorization requests are required by some insurance companies before certain procedures or specialist visits. Like the Alabama Medicaid Referral form, they require detailed patient information, potential diagnoses, and the medical necessity for the requested service.
Patient’s Medical History Form: While primarily focused on gathering patient history, this form shares similarities with the Alabama Medicaid Referral form in that both require comprehensive demographic details and medical background information to provide context for ongoing care.
Insurance Claim Form: An insurance claim form is requested after treatments and services are rendered. It bears resemblance to the Alabama Medicaid Referral form because both require accurate patient and provider information to ensure proper billing and reimbursement processes.
Health Assessment Questionnaire: Health assessment questionnaires evaluate patient health issues and needs, similar to the Alabama Medicaid Referral form. Both documents allow healthcare providers to collect and assess pertinent patient data necessary for appropriate referrals or further evaluations.
Home Health Care Referral Form: Used by primary care providers to recommend home health services, this document mirrors the Alabama Medicaid Referral form. It necessitates detailed information about the patient’s condition, provider details, and necessary services for effective continuity of care.
Emergency Room Referral Form: An emergency room referral form serves to guide patients needing urgent care to appropriate medical personnel. Like the Alabama Medicaid Referral form, it includes patient demographics, contact information, and the specific reason for the emergency consultation.

Dos and Don'ts

When filling out the Alabama Medicaid Referral form, there are some best practices to follow and some common mistakes to avoid:

Do: Ensure all dates are clearly filled in, including today's date and the referral date.
Don't: Skip providing the patient's full information, including name, Medicaid number, and date of birth.
Do: Include the primary physician’s information accurately, including their signature.
Don't: Use stamped or copied signatures for the primary physician; an original signature is a must.
Do: Specify the type of referral clearly, selecting the correct option based on the patient's needs.
Don't: Forget to indicate the valid length of the referral, as omitting this detail can make the referral invalid.
Do: Clearly note the reason for the referral and any other diagnosed conditions.
Don't: Overlook submitting the findings to the primary physician in the requested manner, whether by mail, email, or fax.

Misconceptions

Misconceptions about the Alabama Medicaid Referral form can lead to confusion and mistakes during the referral process. Here are eight common misconceptions:

Only the primary physician can complete the form.
This is incorrect. While the primary physician must provide their information, if there's a screening provider involved, they also need to complete and sign the form, particularly for EPSDT screenings.
Any signature is acceptable on the referral form.
This is a misconception. The primary physician's signature needs to be either printed, typed, or stamped along with an original signature. Stamped or copied signatures will not be accepted.
All referrals are the same.
In reality, there are various types of referrals indicated on the form, including Patient 1st, EPSDT, Case Management, and Lock-In referrals. Each type has different procedures and requirements.
The referral is valid forever once submitted.
This is not true. It is essential to indicate the length of the referral on the form, specifying the number of visits or duration for which the referral is valid. Without this information, the referral may be deemed invalid.
Consultants can choose to ignore communication requirements.
Consultants are required to follow the specified communication preferences of the primary physician to ensure relevant findings and treatments are reported back effectively.
The form does not need to specify the reason for referral.
This belief is misleading. It is crucial to include the reason for referral by the primary physician to ensure the consultant understands the medical necessity behind the referral.
Referrals do not need to be updated once made.
This is a misconception. If any additional conditions are identified by the primary physician during the initial exam, these must be noted in the "Other Conditions/Diagnosis" section of the form.
The Alabama Medicaid website is hard to navigate, and help is not available.
While some may find the website complex, resources are available, including the Alabama Medicaid Provider Manual, which offers detailed instructions for referring and billing processes.

Understanding these misconceptions can help individuals navigate the Alabama Medicaid Referral form with confidence and accuracy.

Key takeaways

The Alabama Medicaid Referral Form (Form 362) serves as a crucial tool for healthcare providers when making referrals for patients enrolled in Alabama Medicaid.
Ensure that you fill out the form completely, including the today's date and the referral date, which indicates when the referral becomes effective.
Provide accurate recipient information including the patient's name, Medicaid number, date of birth, address, and contact details of the parent or guardian.
The primary physician's information is essential. An original signature from the primary care physician or their designee is required for hard copies; stamped or copied signatures are not acceptable.
Identify the type of referral correctly, as options include Patient 1st, EPSDT, Case Management, and others. This selection dictates the next steps in patient care.
Clearly indicate the length of the referral, specifying the number of visits or duration for which the referral is valid. This information is necessary to ensure the consultation stays within approved guidelines.
Indicate the specific things the consultant is authorized to do. Options may include evaluation only, treatment only, or evaluation and treatment.
Consultant information must be provided. This includes the consultant's name, address, and telephone number to facilitate communication.
Lastly, determine how the primary physician prefers to receive findings from the consultant, whether by mail, email, fax, or phone call. This ensures timely feedback on patient care.