Get Ma Tempus Unlimited Consumer Referral Form 2021-2025

Filling out the MA Tempus Unlimited Consumer Referral Form online is a straightforward process that enables users to provide essential information for referral purposes. This guide will walk you through each section of the form, ensuring you can complete it accurately and efficiently.

Follow the steps to fill out the form easily.

1. Click ‘Get Form’ button to access the form and open it in the designated editor.
2. Enter the referral date in the appropriate field, as this will help track the timing of the referral.
3. Provide the TEMPUS assigned consumer number if available; otherwise, leave it blank.
4. Fill in the consumer's full name, ensuring it matches their identification.
5. Input the consumer's email address for communication purposes.
6. List the consumer's phone number, making sure to indicate whether it is a cell or home phone.
7. Complete the home address section, verifying that all details are correct, including street address, city, state, and ZIP code.
8. If applicable, provide the mailing address in the designated field.
9. Enter the social security number, date of birth, and gender. Choose 'M' for male or 'F' for female.
10. Fill in the MassHealth MMIS number, as well as the SCO/OC/PACE ID number, if available.
11. Specify if the consumer is a minor by selecting 'Yes' or 'No.'
12. Indicate the primary language spoken by the consumer.
13. If applicable, list the names and relationships of the parents or guardians of a minor child.
14. State whether the consumer has previously received PCA services or owned a business by selecting 'Yes' or 'No.' If yes, provide the EIN.
15. Select the care program in which the consumer is enrolled, such as FFS, SCO, One Care, or PACE.
16. If applicable, provide the corresponding agency's name for the selected care program.
17. Fill out the surrogate or authorized person's information, including name, email, phone, address, and relationship to the consumer.
18. Specify where the welcome package should be mailed, either to the agency, consumer, or surrogate/AP.
19. Indicate whether a hard copy should be mailed to Tempus by selecting 'Y' or 'N.'
20. Provide the skills trainer or case manager's name, email, phone number, and extension if applicable. Include fax number as required.
21. Review all entered information for accuracy before finalizing the submission.
22. Once completed, save changes, download the form, print it if necessary, or share it as required.

Complete the MA Tempus Unlimited Consumer Referral Form online today to ensure a seamless referral process.