Get Pa Magellan Behavioral Health Initial Referral For Family-based Services 2022-2026

Completing the PA Magellan Behavioral Health Initial Referral For Family-Based Services form is an essential step in accessing necessary behavioral health services for individuals and families. This guide will walk you through the process of filling out the form online, ensuring you provide all the required information accurately and effectively.

Follow the steps to complete the referral form accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred viewing application.
2. Provide the date of referral in the designated field at the top of the form.
3. Fill in the referring agency details, including the agency name, staff name, phone number, and fax number.
4. Input the prescribing doctor's name, email, and phone number in the appropriate fields.
5. Complete the member’s personal information sections, including their name, preferred name, date of birth, medical assistance ID number, gender/pronouns, age, race/ethnicity, languages spoken, and grade.
6. List caregiver and legal guardian information, including their names, relationships, and contact details.
7. Document the home address and additional contact information for the member.
8. Provide details about siblings or others living at home, including their names, ages, and relations.
9. Indicate if there are other agencies involved with the member, along with contact names and numbers.
10. Document the DSM-5 diagnosis and any medications the member is currently taking, including medication names, dosages, and prescribing doctors.
11. Assessment fields related to the member's behavior, symptoms, and level of risk must be filled out comprehensively.
12. If applicable, describe current out-of-home placement information along with contact details.
13. Complete the referral information with the name of the person who completed the form, their title, and the date.
14. Indicate if this referral is an expedited request, ensuring to secure required signatures where applicable.
15. After filling out all sections of the form, review the information for accuracy before saving changes.
16. Once satisfied, download, print, or share the form as needed.

Start completing your PA Magellan Behavioral Health Initial Referral for Family-Based Services form online today!