Get Cbas Inquiry / Request Form This Referral Is Valid For 30 ...

Filling out the CBAS Inquiry / Request Form is an essential step for providers or CBAS centers to facilitate delivering services to qualified individuals. This guide provides clear, step-by-step instructions to assist you in completing the form efficiently and accurately.

Follow the steps to complete the CBAS Inquiry / Request Form online.

1. Press the ‘Get Form’ button to obtain the CBAS Inquiry / Request Form and open it for editing.
2. Begin by entering the patient’s name in the designated field. Ensure the name is spelled correctly for accurate identification.
3. Input the date on which you are filling out the form, along with the patient's date of birth (DOB). This helps in further verification.
4. Fill in the member ID number, which is critical for processing the request. Include the line of business associated with the member (Medicare, Dual, Medi-Cal).
5. Provide the patient’s address, ensuring all details are correct to avoid any delays.
6. Enter the patient’s contact number. This should be a phone number where they can be reached easily.
7. Detail the referring provider or CBAS center's information by filling in the names and contact numbers. This helps streamline communication.
8. Specify the CBAS center you are requesting for and include any fax numbers along with the complete address of the referring provider or CBAS center.
9. Note the date of the referral in the provided field. This is important for tracking the validity period of the referral.
10. In the section labeled 'Functional, BH, Clinical Reasons for Potential Eligibility for CBAS Services,’ provide a detailed explanation of the functional issues, mental health concerns, or medical diagnosis related to the patient's eligibility.
11. If you require more space for your explanation, attach additional documents as necessary. Make sure to label them appropriately.
12. Remember, this referral is valid for only 30 days. After completing the form, ensure you fax the request to 1-800-811-4804. For any inquiries, you may contact the Molina Utilization Management Department.
13. Once you have filled out all sections and verified the information, save changes, and consider downloading, printing, or sharing the form as necessary.

Complete your CBAS Inquiry / Request Form online today to ensure timely processing of services.