Get State Healthchek Plan Referral Form - Ohiohcp

This guide provides a step-by-step approach to accurately complete the State Healthchek Plan Referral Form online. Whether you are assisting someone or filing for yourself, these instructions will help ensure that all required information is properly filled out.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the State Healthchek Plan Referral Form and open it in your preferred document editor.
2. Begin by entering the consumer information. Make sure to clearly include the last name, first name, date of birth, Medicaid number, Social Security number, phone number, and street address, along with the city and zip code.
3. Specify the diagnosis of the individual and the name of the ordering or referring physician.
4. Answer the questions regarding the individual's enrollment in a DD waiver and HMO. If the person is enrolled, you need to stop and contact the applicable manager for authorization. If not, proceed to the next questions.
5. Indicate whether the individual has Medicaid Fee for Service. If they do not, stop here, as the individual is not eligible for HealthChek. If Medicaid is not held, contact County DJFS for application.
6. Determine if the consumer is under 21 years old. If yes, indicate the services sought from the provided options, including Home Health. If no, the individual does not qualify for HealthChek.
7. For individuals over 21, note if they had a three consecutive overnight hospital stay. Based on their response, refer to the appropriate services for either State Plan Increased Home Health Services or State Plan Home Health Services.
8. Provide the referring entity's information, including the provider home health agency, contact name, and contact phone number. Also, include an alternative phone number.
9. Complete the contact information for arranging an assessment, detailing the name, phone number, relationship to the consumer, and alternative phone number.
10. Review all entered information for accuracy. Once confirmed, save your changes, and choose the options to download, print, or share the form as needed.

Ensure your documents are complete and accurate by using this guide to fill out the form online today.