Get Tx Primary Care Case Management (pccm) Referral Form 2007-2025

Filling out the TX Primary Care Case Management (PCCM) Referral Form online can be straightforward with the right guidance. This document is essential for providing referrals to healthcare providers and ensuring that patients receive the necessary care.

Follow the steps to complete your PCCM Referral Form online.

1. Press the ‘Get Form’ button to access the PCCM Referral Form and open it for editing.
2. In the Primary Care Provider Information section, fill in the name of the primary care provider, the contact name, telephone number, NPI, and TPI. Ensure that all details are current and accurate.
3. In the Client Information section, provide the client's name, Medicaid number, date of birth, referral date, and telephone number. Verify that the provided information matches the client’s records.
4. If the referring provider is different from the primary care provider, complete the Referring Provider Information section with the necessary details such as name, contact name, telephone number, NPI, and TPI.
5. In the Consulting Provider/Facility section, input the provider or facility name, their telephone number, and address. Also, specify the appointment time and date along with the Medicaid number if known.
6. Select the reason for the referral from the options provided, such as evaluation only, evaluation and treatment, or other specified reasons.
7. In the Consultant comments field, add any additional notes that might be relevant to the consultation.
8. Ensure the consultant signature and date are included at the end of the form. Make sure all signatures are dated accurately.
9. Once all required fields are filled out, you can save changes, download, print, or share the completed form as needed.

Complete your TX Primary Care Case Management (PCCM) Referral Form online today for efficient healthcare referrals.