Loading
Get Care Management Referral Form Pdf - Buckeye Health Plan
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Care Management Referral Form PDF - Buckeye Health Plan online
Completing the Care Management Referral Form is a straightforward process that helps refer a Buckeye Community Health Plan member to the Care Management Program. This guide will walk you through each section of the form to ensure accurate and efficient submission.
Follow the steps to complete the form with ease.
- Press the ‘Get Form’ button to access the Care Management Referral Form and open it in your preferred editor.
- In the first section, enter the date of the referral.
- Provide the member's full name in the designated field.
- Fill in the member’s date of birth accurately.
- Input the MMIS ID number associated with the member.
- Complete the member’s address with current and accurate information.
- Enter the member's phone number clearly.
- Select the reason for the referral by checking the appropriate box, including options like non-compliance to treatment plan, complex medical issues, high emergency room usage, among others.
- If necessary, use the space provided to elaborate on the reason for the referral.
- Provide the name of the referring provider in the next field.
- Fill in the provider’s phone and fax number for contact purposes.
- Indicate who the referral is requested by in the corresponding section.
- Fax the completed form to 1-866-353-8315, addressed to CM Manager, or if preferred, call in the referral to 1-866-246-4359.
Complete the Care Management Referral Form online to support a member in need.
The payer ID for Buckeye Medicaid is vital for the correct processing of claims. By having the right payer ID at your fingertips, you can avoid unnecessary delays and complications. Be sure to check with Buckeye Health Plan for the most updated information. To support your workflow, the Care Management Referral Form PDF - Buckeye Health Plan gives you a simplified way to manage submissions.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.