Healthy connections referral form idaho 2026

1. Click ‘Get Form’ to open the Healthy Connections Referral Form in the editor.
2. Begin by filling out the Medicaid Participant Information section. Enter the Patient Name, Date, Medicaid ID #, DOB, and Appointment Date.
3. 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.
4. Indicate how you would like the referral sent by checking either 'Referral Mailed' or 'Referral Faxed'.
5. Provide details for the Name of Specialist/Provider, their Address, and Phone Number. If applicable, specify the diagnosis/problem for which you are referring.
6. Select the Type of Service Requested by checking relevant boxes such as 'Evaluate & Recommend Treatment' or 'Surgery if needed'.
7. Complete any additional sections regarding Mental Health Services or Developmental Disability Services as necessary.
8. Finally, ensure that all required fields are filled out and review your entries before submitting.

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