Get Medicaid Referral Form 2020-2025

Navigating the Medicaid Referral Form can feel overwhelming, but with the right guidance, you can complete it efficiently online. This guide provides a step-by-step approach to help you accurately fill out each section of the form, ensuring that all necessary information is included.

Follow the steps to successfully fill out the Medicaid Referral Form.

1. Click ‘Get Form’ button to obtain the Medicaid Referral Form and open it in your preferred editing tool.
2. Enter today's date at the top of the form. This marks when the form is completed.
3. Fill in the Medicaid recipient information, including the recipient’s name, address, date of birth, telephone number, and, if applicable, the name of their parent or guardian.
4. Provide the primary physician's details. Ensure you include their full name, address, telephone number, fax number, email, NPI number, and Medicaid provider number.
5. If applicable, fill in the screening provider's information, including name, address, and contact details, ensuring they sign if the referral is based on an EPSDT screening.
6. Select the type of referral by checking the appropriate box and provide the screening date if necessary.
7. Specify the length of the referral by indicating the valid duration in months or visits.
8. Indicate what the referral is valid for by checking the boxes that apply, such as evaluation only, treatment only, or other specified options.
9. State the reason for referral by the primary physician, detailing the medical condition or reasons for the referral.
10. Note any other conditions or diagnoses identified by the primary physician during the initial examination.
11. Complete the consultant information section with the consultant's name, address, and telephone number.
12. Indicate how the findings should be submitted to the primary physician, choosing from options such as mail, email, fax, or by phone.
13. After all sections are completed, review the form for accuracy. Save any changes, and download, print, or share the form as needed.

Complete the Medicaid Referral Form online today to ensure timely processing of your referral.