Pre Interview Employer Form by eyg87181


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									                                   MEANINGFUL DAY SERVICES, INC.
                                       P.O.Box 1110, Brownsburg IN 46112
                                     Phone 317-858-8630 -- Fax 317-858-8715
                               NEW CONSUMER REFERRAL FORM                                                Revised 8/22/07

          Referral Date                                                  Taken by:
         Referral From:                                           Provider Name:
        Exp. Start Date:                                                   Service:
      Contact Person:                                           Currently on NOA?
       Contact Phone #                                         Consultant Name:
  How did you hear about us?
Do we have your permission to send this information to our therapist(s) electronically?

Consumer Information
    Consumer Name:                                                   2nd Phone #
               Address                                                        County
         City, State Zip                                               Medicaid #
        Phone Number                                                       Birthdate
             Diagnoses                                                          SS#
  Doctor's name and #                                              NOA Annual Date
                           (Doctor's name, phone number and address required for OT, Speech, and Counseling referrals)

Funding Source
       Medicaid ___________ Waiver ___________            Private Pay ___________ *Private Insurance ___________
                                       *Use Insurance Form to obtain needed info for OT, Speech & Counseling only.

Guardian Information                                                          Name
               Address                                             Phone Number
         City, State Zip                                             Relationship

Casemanager Information                                     Casemanager Name:
               Address                                            E-mail address:
         City, State Zip                                         Agency Phone #
        Phone Number                                                 2nd Phone #


                                    PERMISSION FOR SERVICES
By signing this form, I hereby approve ____________________________________ (Consultant Name)
of MDS ,Inc. to provide services for:
                           _____ Myself
                           _____ The consumer indicated above for whom I am guardian.
The service
 approved is:              _____   ABA                             _____   Music Therapy
                           _____   Behavior Management             _____   Occupational Therapy
                           _____   Counseling                      _____   Recreation Therapy
                           _____   Day Services                    _____   Speech Therapy
My signature approves this service.

Signature of Consumer or Guardian                                  Date of Signature
                                  Consumer Name:
Contact Information
                                  Date   Time      Person contacted/Results
First Phone Contact Attempt


Second Phone Contact Attempt


Third Phone Contact Attempt


Office Contact


                                  Date   Time
     Scheduled Interview

   Summary of Interview

Hours Needed

                           Date   Time   Method
Forwarded to the Office
                              Meaningful Day Services, Inc.
                                         P.O. Box 1110
                                      Brownsburg, IN 46112

                                Private Insurance Form
Person taking information:                                                  Date:

       Client Name                                                        Service Counseling
    Client Address                                                        Phone:
        Medicaid #                                   Diagnosis

                                      Insured Information

     Insured Name                                            Employer
      Insured DOB                                             Group #
   Insured Phone #                                           Member #
  Insured Address                                                 Sex

                               Insurance Company Information

   Company Name                                         Ins. Co. Phone
    Claim Address

                                      Benefit Information

       Name of Insurance Rep Spoke To:

            Effective Date

      Pre-certification Required?                  Phone to Pre-Certify
  Pre-certification Requirements:

Does coverage include out-of-network benefits?
    If not, what needs to be done to credential?

 Addtl Information:

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