Buckeye Health Plan Care Management Referral free printable template

Care Management Referral Form Please use this form to refer a Buckeye Community Health Plan member to the Care Management Program Date: Member Name: Members Date of Birth: MMS ID #: Member Address:

How to fill out care management form

How to fill out Buckeye Health Plan Care Management Referral Form

1. Obtain the Buckeye Health Plan Care Management Referral Form from the official website or by contacting customer service.
2. Fill in the patient's personal information including name, date of birth, and contact details.
3. Provide the insurance information, including the Buckeye Health Plan policy number.
4. Detail the reason for the referral clearly, including any specific concerns or needs of the patient.
5. Include relevant medical history or diagnosis, if applicable, to assist care managers in understanding the patient's situation.
6. Complete any additional sections of the form that may ask for information about existing support services or interventions.
7. Review the form for accuracy and completeness before submission.
8. Submit the completed form according to the provided instructions, either electronically or via mail.

Who needs Buckeye Health Plan Care Management Referral Form?

1. Individuals enrolled in Buckeye Health Plan who require additional support or management for their health conditions.
2. Caregivers or family members of patients who need assistance in accessing care management services.
3. Healthcare providers looking to refer patients for care management services under Buckeye Health Plan.

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What is Buckeye Health Plan Care Management Referral Form?

The Buckeye Health Plan Care Management Referral Form is a document used to refer members for care management services within the Buckeye Health Plan.

Who is required to file Buckeye Health Plan Care Management Referral Form?

Providers and professionals involved in the care of a member are required to file the Buckeye Health Plan Care Management Referral Form when they identify a need for care management services.

How to fill out Buckeye Health Plan Care Management Referral Form?

To fill out the Buckeye Health Plan Care Management Referral Form, complete the required fields including member information, reason for referral, and any relevant medical history. Ensure that all necessary signatures are obtained.

What is the purpose of Buckeye Health Plan Care Management Referral Form?

The purpose of the Buckeye Health Plan Care Management Referral Form is to initiate the process of care management for members who may benefit from additional support and resources in managing their health conditions.

What information must be reported on Buckeye Health Plan Care Management Referral Form?

The information that must be reported includes member's personal details, diagnosis, specific needs for care management, current treatments, and any concerns or observations by the referring provider.