Get the free STATE HEALTHCHEK PLAN REFERRAL FORM - ohiohcp

OHIO DEPARTMENT OF MEDICAID STATE HEALTHCARE PLAN REFERRAL FORM Please type or print legibly SUBMISSION DATE: CONSUMER INFORMATION Last Name: Date of birth: First Name: Medicaid Number: Social Security

How to fill out state healthchek plan referral

How to fill out a State Healthchek plan referral:

1. Obtain the necessary forms or referral documents from your healthcare provider or the State Healthchek program.
2. Fill in your personal information accurately, including your name, date of birth, contact information, and any identification numbers provided by the program.
3. Provide information about your healthcare provider, including their name, address, and contact information.
4. Clearly state the reason for the referral and include any relevant medical history or symptoms that prompted the need for the referral.
5. Attach any supporting documentation or medical records that may be required or helpful for the referral process.
6. Review the completed referral form for accuracy and completeness, making sure all required fields are filled out.
7. Sign and date the referral form, demonstrating your consent and authorization for the referral.
8. Keep a copy of the completed referral form for your records before submitting it to the appropriate healthcare provider or the State Healthchek program.

Who needs a State Healthchek plan referral?

1. Infants and children who are enrolled in Medicaid or the Children's Health Insurance Program (CHIP).
2. Individuals up to the age of 21 who have Medicaid and are eligible for the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.
3. Individuals with developmental or intellectual disabilities who are eligible for Medicaid or CHIP.

It is important to note that the specific eligibility criteria and requirements for a State Healthchek plan referral may vary depending on the state you reside in. It is recommended to consult with your healthcare provider or the State Healthchek program for detailed information and assistance in filling out the referral form accurately.

For pdfFiller’s FAQs

What is state healthchek plan referral?

State healthchek plan referral is a process for referring individuals to receive health assessments and services for children under the age of 21 who are eligible for Medicaid.

Who is required to file state healthchek plan referral?

Healthcare providers and caregivers are required to file state healthchek plan referrals for eligible children under the age of 21.

How to fill out state healthchek plan referral?

To fill out a state healthchek plan referral, healthcare providers or caregivers must complete the necessary forms and submit them to the appropriate state agency.

What is the purpose of state healthchek plan referral?

The purpose of state healthchek plan referral is to ensure that eligible children receive necessary health assessments and services to maintain their well-being.

What information must be reported on state healthchek plan referral?

State healthchek plan referral must include the child's demographic information, medical history, and the reason for the referral.

How do I edit state healthchek plan referral online?

pdfFiller not only lets you change the content of your files, but you can also change the number and order of pages. Upload your state healthchek plan referral to the editor and make any changes in a few clicks. The editor lets you black out, type, and erase text in PDFs. You can also add images, sticky notes, and text boxes, as well as many other things.

Can I edit state healthchek plan referral on an iOS device?

Yes, you can. With the pdfFiller mobile app, you can instantly edit, share, and sign state healthchek plan referral on your iOS device. Get it at the Apple Store and install it in seconds. The application is free, but you will have to create an account to purchase a subscription or activate a free trial.

How do I complete state healthchek plan referral on an Android device?

Use the pdfFiller Android app to finish your state healthchek plan referral and other documents on your Android phone. The app has all the features you need to manage your documents, like editing content, eSigning, annotating, sharing files, and more. At any time, as long as there is an internet connection.