The Alabama 450 form is a document used by healthcare providers to formally dismiss a patient from their practice, specifically within the Medicaid system. This form captures essential information about the patient, including their name, date of birth, and reason for dismissal, ensuring that the process is clear and documented. It also outlines the necessary steps for providers to follow, including notifying the patient and providing referrals if needed.
The Alabama 450 form serves as a critical tool in the healthcare landscape, specifically designed for the dismissal of patients from a Primary Medical Provider's (PMP) panel. This form captures essential information about the recipient, including their name, date of birth, Medicaid number, and contact details, ensuring that all relevant data is readily available. It also prompts the provider to specify the reason for dismissal, which could range from recipient behavior to non-compliance with treatment. This structured approach not only facilitates clear communication between healthcare providers and patients but also emphasizes the importance of documentation in the dismissal process. Additionally, the form requires the provider to list any referrals made within the last 30 days, reinforcing the need for continuity of care. Aftercare management is also addressed, as providers must indicate whether they would be willing to accept the recipient back into their practice. By adhering to the guidelines outlined in the Alabama Medicaid Billing Manual, the form ensures that all dismissal requests are handled with due diligence, requiring 30 days' written notice to the patient. This process safeguards both the rights of the recipient and the responsibilities of the provider, maintaining a balanced approach to patient care.
Patient 1st Recipient Dismissal Form
.
Recipient Name _________________________________________________ DOB ___________________
Medicaid Number _____________________________________ Gender Male Female
Address __________________________________________________ Telephone # __________________
City __________________________________________________ State ________ Zip _____________
Name ____________________________________________ NPI # ________________________________
Reason for Dismissal
Recipient Behavior Non Compliance w/treatment Other _____________________________
To assist you and the recipient in the dismissal process, please list the name and telephone number of any referral for this recipient within the last 30 days or send copy of the referral.
Referred To
Diagnosis
Date
Length of Referral
After care management, would you accept this recipient back in your practice? Yes No
For Medicaid Office Use Only
Refer to Care Coordinator
Refer to Lock-in Program
A Primary Medical Provider may request removal of a recipient from his panel due to good cause.* All requests for patients to be removed from a PMP’s panel should be submitted on this form and provide the enrollee 30 days written notice. The request should contain documentation as to why the PMP does not wish to serve as the recipient’s PMP.
*IAW: ALABAMA MEDICAID BILLING MANUAL CHAPTER 39
Please send form to Patient 1st Fax at (334) 353-3856.
FORM 450
www.medicaid.alabama.gov
Revised 10/13/2011
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