Get Rem Intake Referral Form 2012

Filling out the Rem Intake Referral Form 2012 online is a straightforward process designed to collect essential patient information for case management. This guide will help you navigate through each section of the form clearly and efficiently.

Follow the steps to successfully complete the Rem Intake Referral Form 2012 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the 'DHMH Use Only' section. Indicate whether the form is 'Incomplete' or 'Complete'. Provide the date assigned and the screener's name along with the date.
3. In the 'County' field, enter the relevant county information, and then provide the fax number (410-333-5426) in the appropriate area.
4. Complete the 'Patient Information' section. Fill out the patient's name, Medicaid number, address, home phone number, apartment number (if applicable), city, state, and ZIP code.
5. Next, enter the patient's date of birth and indicate their managed care organization (MCO) if applicable. Include work phone number, sex (M or F), and the patient's social security number.
6. Add the contact person's details, including their phone number, address, apartment number, city, state, and relationship to the patient.
7. Provide information about the referring physician. This includes their name, phone number, specialty, and license number.
8. Include information for the primary care physician (PCP) and any consulting physician if applicable. Repeat the same fields as for the referring physician.
9. Proceed to the 'Clinical Information' section and record the primary and secondary diagnosis along with their ICD-9 codes.
10. Complete the 'Supporting Information' section by attaching copies of relevant documents including history, physical, laboratory/pathology, radiology, and consultations. Add any additional comments if necessary.
11. Finally, ensure that an MD signature and date are provided before completing the form.
12. Once all sections are filled out, you can save changes, download, print, or share the form as needed.

Complete the Rem Intake Referral Form 2012 online today to streamline the referral process.