Follow the steps to successfully fill out the form online.

1. To begin, click the ‘Get Form’ button to obtain the form and open it in your chosen editor.
2. In the section labeled 'Member Name', enter the member’s last name, first name, and middle initial as appropriate.
3. Input the member's ID number, ensuring that it contains nine digits, and include their phone number in the designated field.
4. In the 'Referred To' section, write down the provider's name. Make sure that this provider is a current Medicaid provider.
5. Fill in the provider's phone number and provider address accurately.
6. Indicate if this is for an initial visit only and specify the evaluation and treatment duration in months. Remember, this cannot exceed 12 months.
7. Clearly outline the reason for the referral and include the diagnosis using appropriate ICD-9 codes.
8. Under the 'Referred by' section, include the name of the primary care provider or case manager, along with their phone number.
9. The referring provider needs to sign the form and date it to validate the referral.
10. In the final section, ensure that you input the referring provider's number and their NPI number, both of which are crucial for processing.
11. Once all information is filled out, save your changes, and you may then choose to download, print, or share the completed form as necessary.

Complete your documents online now for a seamless experience.