Get Gateway Health Member Outreach Form 2018-2025

Filling out the Gateway Health Member Outreach Form online is a straightforward process that ensures essential health information is communicated effectively. This guide will provide you with step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to acquire the Gateway Health Member Outreach Form and open it in your preferred editor.
2. In the first section, provide the member's full name, age, Gateway Health ID number, date of birth, and the date of last EPSDT screen if the member is under 21 years old.
3. Complete the parent or guardian's name and their relationship to the member. Include a contact phone number with the area code.
4. Fill in the name of the primary care provider (PCP), along with their provider ID number, contact person's name, and relevant phone number.
5. Indicate the date this referral was sent to Gateway Health Plans (GHP), and specify the reasons for referral in the designated section. Choose from listed options such as overdue EPSDT screening, missed appointments, or elevated blood lead levels.
6. If applicable, provide the details of any overdue EPSDT screening by specifying the last screen date, and any immunizations the member is behind on.
7. For chronic no-shows, list the dates of missed appointments and the reasons for these absences.
8. Document the most recent blood lead level draw date along with the result, and the date a script was given for blood lead level assessment.
9. Note whether the member was notified by mail or phone call and record the corresponding dates.
10. Clearly list any referral services, detailing the physician or practice name, phone number, and specialty.
11. Include any additional comments or information that may be relevant in the provided section.
12. Once all sections are completed, you can save the changes, download the form, print it, or share it as necessary.

Get started on filling out your Gateway Health Member Outreach Form online today!