The Alabama 362 form serves as a critical tool for Medicaid referrals within the state of Alabama. This form facilitates communication between primary care physicians and specialists, ensuring that patients receive the appropriate care. Accurate completion of the form is essential for the timely processing of referrals and the overall effectiveness of Medicaid services.
The Alabama 362 form serves as a crucial tool in the Medicaid system, facilitating communication between healthcare providers and ensuring that patients receive the appropriate care they need. This form is specifically designed for referrals within the Medicaid program, capturing essential details about the recipient, including their name, date of birth, and contact information. It also includes vital information about the primary physician and any screening providers involved in the patient's care. By outlining the type of referral—whether for evaluation, treatment, or case management—the form helps streamline the process and clarifies the purpose of the referral. Additionally, it specifies the duration of the referral, indicating how long the referral is valid, which can be measured in months or visits. The form also allows for cascading referrals, meaning that if a consultant identifies additional conditions, further referrals can be made. Importantly, the Alabama 362 form emphasizes the need for confidentiality, ensuring that personal health information is handled appropriately throughout the referral process. This comprehensive approach not only aids in effective patient management but also aligns with Medicaid's commitment to providing quality healthcare services to its recipients.
ALABAMA MEDICAID REFERRAL FORM
Today’s Date _________________
PHI-CONFIDENTIAL
ImportantNPIInformation
See Instructions
Date Referral Begins _________________
MEDICAID RECIPIENT INFORMATION
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
Fax # with Area Code
Email
NPI #
Medicaid Provider #
Signature
TYPE OF REFERRAL
❑
Patient 1st
Lock-in
EPSDT
Screening Date ______________________
Patient 1st/EPSDT
Screening Date ____________________
Case Management/Care Coordination
Other
LENGTH OF REFERRAL
Referral Valid for __________ month(s) or __________ visit(s) from date referral begins.
REFERRAL VALID FOR
❑Evaluation Only
❑Evaluation and Treatment
❑Referral by consultant to other provider for identified condition (cascading referral)
❑Referral by consultant to other provider for additional conditions diagnosed by consultant (cascading referral)
❑Treatment Only
❑Hospital Care (Outpatient)
❑Performance of Interperiodic Screening (if necessary)
Reason for referral by PMP
Other conditions/diagnoses identified by PMP
CONSULTANT INFORMATION
Consultant Name
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. 7-30-10
www.medicaid.alabama.gov
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