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Healthy connections referral form idaho 2026
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- Click ‘Get Form’ to open the Healthy Connections Referral Form in the editor.
- Begin by filling out the Medicaid Participant Information section. Enter the Patient Name, Date, Medicaid ID #, DOB, and Appointment Date.
- In the Medicaid Provider & Referral Information section, select the Length of Referral from options such as '1 Visit', '3 Months', or '12 Months'. Ensure it does not exceed 12 months.
- Indicate how you would like the referral sent by checking either 'Referral Mailed' or 'Referral Faxed'.
- Provide details for the Name of Specialist/Provider, their Address, and Phone Number. If applicable, specify the diagnosis/problem for which you are referring.
- Select the Type of Service Requested by checking relevant boxes such as 'Evaluate & Recommend Treatment' or 'Surgery if needed'.
- Complete any additional sections regarding Mental Health Services or Developmental Disability Services as necessary.
- Finally, ensure that all required fields are filled out and review your entries before submitting.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2009 | 4.8 Satisfied (60 Votes) |
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health connections idaho
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