Get Rem Intake And Referral Form

Completing the Rem Intake And Referral Form is essential for ensuring proper processing of referrals and patient care. This guide offers clear, step-by-step instructions to help you fill out the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Begin by providing your referral source information, including the name, address, telephone number, and fax number.
3. Next, fill out the patient information section with the patient’s first name, middle initial, last name, and Medical Assistance (MA) number.
4. Complete the patient’s complete address, including any apartment number, date of birth, telephone number(s), sex, and Social Security Number.
5. Include the Managed Care Organization (MCO) information, specifying the MCO name, contact person, and their telephone number if known.
6. In the patient contact information section, provide details of the contact person, including their complete address, telephone number(s), and their relationship to the patient.
7. Input the referring physician's information by stating the physician’s name, specialty, license number, and telephone number. A signature from the referring physician is required.
8. At the top of page 2, enter the patient’s name and birth date again.
9. Document the primary and secondary clinical diagnoses, including ICD-9 codes, which are essential for verifying eligibility for REM enrollment.
10. Complete the supporting information section, which requires specific information related to each REM diagnosis. Ensure to follow the recommended medical documentation guidelines pertaining to the REM disease list.
11. Remember that a physician’s signature is required at the bottom of page 2.
12. Once you have filled out all sections, you can save your changes, download the form, print it, or share it as needed.

Complete your Rem Intake And Referral Form online for prompt processing.