Recommended Physician Referral Form Instructions
Providers are instructed in Subsection 5.2 of Clinical Coverage Policy 12 B to obtain a
physician’s written order that details the need for the initiation of HIV Case
The intent is that the physician is making a referral to evaluate the need for services.
The physician is not “ordering” services. The wording in the instructions and on the
recommended form below reflects the intention of the Division of Medical Assistance.
• Providers shall obtain a physician’s written referral that details the
need for the initiation of HIV Case Management Services.
• An additional physician’s referral is needed for ongoing case
management of more than 2 months (maximum of 32 hours).
• Providers need to obtain a written physician’s referral annually if the
recipient continues to have unmet needs that require case
• A separate referral form is required for each of the 3 time frames listed
• Although the use of this form is not mandated, it is highly
Client ID #:___________ Date: _________
(INSERT AGENCY NAME)
HIV CASE MANAGEMENT
PHYSICIAN REFERRAL FORM
SUBMIT FORM TO THE HIV CASE MANAGEMENT PROVIDER/AGENCY
COMPLETE THIS FORM AND SEND TO:
PHYSICIAN OPTIONS FOR SUBMISSION TO THE HIV CASE MANAGEMENT PROVIDER/AGENCY:
SUBMIT VIA FAX AT: (___) _____________
OR SUBMIT VIA MAIL TO: _____________________________________
*PHYSICIAN MAY ALSO SUBMIT THE COMPLETED FORM VIA THE CLIENT TO DELIVER TO THE HIV CASE MANAGEMENT
PROVIDER IN PERSON.
CLIENT NAME: DOB: GENDER: MALE FEMALE TRANSGENDER
RESIDENCE/PERMANENT ADDRESS: CITY: COUNTY: ZIP:
CLIENT PHONE: PRIMARY LANGUAGE:
EMERGENCY CONTACT NAME: RELATIONSHIP:
IF UNDER 18, NAME OF LEGAL GUARDIAN: RELATIONSHIP:
PROVIDER/AGENCY NAME: PROVIDER/AGENCY CONTACT NUMBER:
PHYSICIAN/PRACTITIONER NAME: FACILITY/PRACTICE NAME:
PHYSICIAN/PRACTICTIONER PHONE: PHYSICIAN/PRACTICTIONER FAX: PHYSICIAN/PRACTICTIONER E-MAIL:
I, , RECOMMEND THAT RECEIVE MEDICAID HIV CASE
MANAGEMENT SERVICES BASED ON A REVIEW OF THE CLIENT’S MEDICAL RECORDS.
I ATTEST TO THE VALIDITY OF THE POTENTIAL CLIENT’S HIV + STATUS.