Referral form 2026

1. Click ‘Get Form’ to open the referral form in the editor.
2. Begin by filling out the Member Information section. Enter the first name, last name, Medicaid ID number, middle initial, social security number, birth date, mailing address, city, state, zip code, home phone, cell phone, and email address.
3. In the Medicaid Providers Receiving Referral section, list at least two providers of the same type or specialty. For each provider, enter their first and last name, Medicaid Provider ID number, and the date of referral.
4. Provide a detailed clinical assessment of the patient in the designated area. Ensure you include any relevant medical findings and treatment plans.
5. Indicate whether the referral is for diagnostic or corrective treatment by checking 'Yes' or 'No'.
6. Complete the Primary Care Physician (PCP) Name section by printing or typing your name along with your Medicaid Provider Number/Taxonomy Code.
7. Sign and date the form in the appropriate fields before submitting it.

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