Use this form to report your childs physical health to their schoolchild care facility. Maryland uniform credentialing form general information only enter a foreign national identification number if you do not have a ssn. Maryland infants and toddlers program referral and feedback form. The original is to be sent to the maryland dhmh and the blue copy to the newborns pediatrician. The maryland health care commission mhcc is a public, regulatory commission with broad authority over health care delivery in maryland. Individual completing this form referral certification is not a guarantee of payment.
If you have questions, please call provider services at 8778423210 1. The maryland universal interhospital handoff transfer form was designed to communicate pertinent and accurate clinical patient care information at the time of transfer to the receiving hospital. The governor, with the advice and consent of the maryland senate, appoints fifteen commissioners that broadly reflect the perspectives of consumers, employers, health care providers, and insurance carriers. Call esi directly at 8007532851 or fax the appropriate form, found below under priorauthorization forms for outpatient pharmacy medications processes through esi. Stat please be sure to bring this form, your health insurance card, picture id, copay and deductible with you, as well as any xray studies pertaining to your scheduled exam. Please check the program or office for the referral parents requesting a referral to the doctors office, can take the referral to the doctors office of. If required referral certification is not a guarantee of payment. Uniform consultation referral form kaiser permanente. You may contact a case manager on business days from 8. All maryland children born on or after january 1, 2015 should have a blood lead test at 12 and 24 months of age. Please allow 10 business days for your nearest dors office to receive and process your referral and set up an appointment for you to meet your new dors counselor. If referral is not signed and dated by the primary care physician, the claim will be denied. Authonzation if blank, 1 visit is assumed if r uired signature.
What we learned was that many states and programs ask for an inordinate amount of information that is simply not nec. The maryland patient referral law limits innovation executive summary over the past several months, this workgroup has to discuss met reform of the maryland patient referral law mprl to protect based payment methods value in this state. Referral and feedback form adapted from the american academy of pediatrics policy statement. Enter the associated 3digit code in the space provided. Program receiving referral please complete this portion and return to the referral source above. Maryland tobacco quitline fax referral form fax number. Preauthorization and utilization management medstar.
Preauthorization and utilization management medstar family. Do not enter national provider identification npi number here. Instructions for child care providers using the maryland. The maryland patient referral law limits innovation executive. Primary care providers must use the maryland uniform consultation referral form pdf when referring medstar family choice members to specialists. The referral will be entered in aware when the referral is received, and the referral date entered in aware will coincide with the referral record e.
Box 207 annapolis, md 214040207 4109742803 zero remittance reports only rate. If your changes result from an outofstate move or a change of provider group, please use the form above instead. Customizing the referral form the universal referral form included in the appendix can be customized to include identifying information about the early childhood intervention program using the referral form. Laws calm legal forms guide petition for appointment of guardian form 1 the petitioner needs to file this form in the county where the minor currently resides if the minor lives out of state they must have real property or other assets in the county step 1 below the heading list the petitioners full legal name and the name age and date of birth for each miner then in part 1 check the box that. The maryland patient referral law limits innovation. To change your phone or fax number, email address or practice address, use the link below. Maryland uniform consultation referral form date of referral.
Appointment of representative aor form centers for medicare and medicaid services cms pdf authorization to release medical information form chinese pdf authorization to release medical information form english pdf authorization to release medical information form spanish pdf act for a family member via kaiser. Call your nearest dors office and well help you complete the referral over the phone. You may contact the health suite personnel through the. Maryland uniform consultant referral form schoolbased. Request a provider manual use this form to request that a kaiser permanente provider manual be sent to you in the mail. Free uniform consultation referral form pdf template form. Role of the medical home in familycentered early intervention services. Maryland uniform consultation referral form maryland physicians.
Esi is the pharmacy benefits manager for maryland physicians care. Due on the 15th of each month section 1 carrier identification company name complete mailing address telephone email address. Medstar family choice follows a basic preauthorization process. Content and description including but not limited to form descriptions, page content, page titles are all properties of form download and its authors. Referral forms adult referral forms are available below in pdf format.
For safety reasons, children under the age of 8 may not be left in the. Downloadable pdfword forms available are properties of their respective owners. Aa policy for determination of rent reasonableness. Fax the universal referral form for services listed below for inoffice place of service 11 or outpatient hospital place of service 22 settings to outpatient intake services at. Payment of benefits is subject to a members eligibility on the date. This is a page on the cms site that provides information about. Referral request form to request a referral, please have the unitedhealthcare community plan members assigned primary care provider pcp complete, sign and submit this form.
Maryland uniform consultation referral form shady grove fertility. A members physician forwards clinical information and requests for services to medstar family choice by phone, fax or infrequently by mail. Fia documents maryland department of human services. Md uniform referral form fill online, printable, fillable. A blood lead test is the only sure way to know whether your child has been exposed to lead. Local health services request form and instructions. Maryland uniform dental consultation referral form form to be used by regulation.
If you have questions, please call provider services at 8778423210. Dhs documents maryland department of human services. If you have questions or are having access problems, please call us toll free at 866 3462362. As a result, all children born on or after 1115 must be tested for lead at ages 12 and 24 months. Referral authorization retroactive referrals are not valid. Ahrq health literacy universal precautions toolkit, 2nd. Prior authorization requests for covered outpatient medications are processed through express scripts, inc. Maryland emergency medical services interhospital transfer. Initial by not initialing, you are giving your permission for the quitline to leave a message. If the baby does not return for outpatient screening, no show status is indicated and the form is forwarded to the state. A referral is for services delivered only by practitioners under contract with m.
Thank you for the referral, the referral was received and the child was found to be. If the reader of this form is not the intended recipient or the employee or agent responsible to deliver it to the intended. Maryland uniform referral form fill out and sign printable pdf. Maryland uniform dental consultation referral form. Maryland early interventioneducation referral and feedback form adapted from the american academy of pediatrics policy statement. T he entire state of maryland is now considered at risk for lead exposure, for children born on or after 1115. If the applicant wishes to be referred to another countys rrp, please state no more than three 3 specific jurisdictions. Referral forms adult specialty referrals health care. If a parentguardian does not consent, keep the screening and score sheet in the childs filea referral does not need to be made. Download forms kaiser permanente community providers. Fill out, securely sign, print or email your maryland uniform referral form. Maryland uniform consultant referral form schoolbased health center health visit report form updated 2015.
See the universal referral program manual and the skills information sheet. Referral certification is not a guarantee of payment. Individual completing this form authorizing signature. Maryland uniform consultant referral form schoolbased health. Payment of benefits is subject to a members eligibility on the date that the service is rendered and to any other contractual provisions of the plan carrier. Refer a patient to a specialist medstar family choice. External referral and authorization form view an example of our new kaiser permanente referral form. Peer recovery support services prss offers peer support for people seeking recovery from substance use andor mental health problems. Z procedures for annual housing and participant recertification. Prior authorization request forms maryland physicians care. In march 2016, maryland implemented the leadfree maryland kids campaign and the updated clinical requirements for blood lead testing of children. Laws calm legal forms guide petition for appointment of guardian form 1 the petitioner needs to file this form in the county where the minor currently resides if the minor lives out of state they must have real property or other assets in the county step 1 below the heading list the petitioners full legal name and the name age and date of birth for each miner then in part 1 check the box.
Maryland early interventioneducation referral and feedback form. Submit the completed uniform consultation referral form to carefirst bluechoice applies to pcp only by fax to 4105056160 or 18003548205. Lead is found in all areas of maryland, from many different sources. Date see carrier instructions authorizing signature. This form does not negate, but is in addition to, the hospitals emtala documentation, necessary medical record.
A universal referral form for use by primary referral sources. Payment of benefits is subject to a members eligibility on the date that the service is rendered and to any other contractual provisions of the plancarrier. University of maryland faculty practice referral form. University of maryland faculty practice referral form return to fdsp front desk 650 w. The referral form can be opened in adobe acrobat reader and the following customized features made to the referral form. Peer support specialists are individuals that are in long term recovery and can share their lived experience to connect clients with the resources and community services that will assist them in being.
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