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  • Medicaid Referral Form

Get Medicaid Referral Form

Instructions for Completing The Alabama Medicaid Agency Referral Form (Form 362) TODAY'S DATE: REFERRAL DATE: RECIPIENT INFORMATION: PRIMARY PHYSICIAN:* SCREENING PROVIDER:* Date form completed Date.

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Related content

Referral Forms - Alabama Medicaid
Referral Forms. In many cases, a referral to another doctor or clinic is needed for...
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PROVIDER REFERRAL FORM MEMBER NAME DATE OF ...
PROVIDER REFERRAL FORM. MEMBER NAME. DATE OF BIRTH. MEDICAID ID NUMBER. PROVIDER NAME...
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Vermont Medicaid Provider Manual VTMedicaid
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What do I need to do? Most specialists require a referral from your primary care provider. Contact your primary care provider to obtain a referral to a specialist.

QI-1 or Qualified Individual (effective February 2023): Income cannot exceed $1,661 per month for an individual. Income cannot exceed $2,239 per month for a couple. Plan First/Pregnant Women/Children (Ages 0-18):* Income after deductions cannot exceed $1,774 per month for a family of 1.

What do I need to do? Most specialists require a referral from your primary care provider.

If a medical emergency is referenced, the provider must submit the PA request within 30 days of the date of service. Supporting documentation must provide evidence that the service was not scheduled and that delays greater than 72 hours would have resulted in serious injury or harm.

Recipients who are proven to have abused or misused the Medicaid program may be "locked in" to one doctor and one drug store, be required to repay the Agency for misspent funds and/or may be suspended from the program for at least one year and until full restitution is made.

The cascading referral permits subsequent providers to refer the recipient to additional providers without a having to request a new referral.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232