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Service Referral Template

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					                                                                                   Current Enrollee Referrals Tracking
Children Rehabilitative Service Program


                                                                                                                                                          If Referral Source is     If Referral Source is
                                     Middle                                                                                      If Referral Source is   AHCCCS Health Plan,      Specialty Service, which   Approved/
Site Code   Last Name   First Name   Initial   CRS Member ID # AHCCCS Status   Referral Type   Referral Date   Referral Source       Other- specify            which one                     one              Denied




57ad652f-0c31-4ef0-8f6b-aaf8ec39eea7.xls- Revised                                                      Page 1 of 5                                                                             Printed on 8/12/2011, 11:28 AM
                                                                               Current Enrollee Referrals Tracking
Children Rehabilitative Service Program


                    Days from Referral
Date of Scheduled        to Sch.         Specialty Service                                                                              Date Received at
  Appointment         Appointment          Referred To       45 day Exempt   Place of Service        Comments   Keyed By   Keyed Date        CRSA

                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0
                            0




57ad652f-0c31-4ef0-8f6b-aaf8ec39eea7.xls- Revised                                               Page 2 of 5                                                Printed on 8/12/2011, 11:28 AM
Field Name       Description                                Data Type       Values
Site Code                                                                   518
                                                                            519
                                                                            520
                 Originating referral site's numeric        Drop-Down       521
                 identifier                                 List
Last Name        Referred Member's last name                Text
First Name       Referred Member's first name               Text
Middle Initial
              Referred Member's middle initial              Text
CRS Member
ID #          Valid CRS Member ID                           Text
AHCCCS Status                                                               Yes
              AHCCCS ID - Leave blank only if                               No
              member is not AHCCCS eligible                 Text
Referral Type                                                               Regular
              A Referral is the request for specialized                     Follow-up
              services from one provider to another                         45 days Exemption
              provider. Use drop-down list to indicate      Drop-Down       Transfer
              referral type.                                List
Referral Date
              Date referral was initiated                   mm/dd/yyyy      Valid Date
Referral                                                                    AHCCCS Health Plan
Source                                                                      Clinic Physician
                                                                            CRS - Flagstaff
                                                                            CRS - Phoenix
                                                                            CRS - Tucson
                                                                            CRS - Yuma
                                                                            Other
                                                                            Primary Care Physician
                                                                            School Nurse
                 Clinic or health care professional         Drop-Down       Specialty Clinic
                 initiating the referral                    List
If Referral    If you are selecting "Other" from the list
Source is      of choices under "Referral Sources",
Other- specify please specify the source here.              Text
If Referral                                                                 APIPA
Source is                                                                   Bridgeway Health Solutions
AHCCCS                                                                      Care 1st Arizona
Health Plan,                                                                Cochise Health Systems
which one                                                                   Evercare Select
                                                                            Health Choice AZ
                                                                            LTC DD DES
                                                                            Maricopa Health Plan
                                                                            Mercy Care Plan
                                                                            PHP/Community Connection
                                                                            Pima Health Plan
                                                                            Pinal/Gila LTC
                                                                            SCAN - LTC
                 Specifies AHCCCS Health Plan initiating                    University Family Care
                 the referral. Use drop-down list to select Drop-Down       Yavapai Long Term Care
                 plan.                                      List



                                                                   Page 3
Field Name     Description                                 Data Type       Values
                                                                           Audiology
If Referral                                                                Cardiac
Source is                                                                  Cerebral Palsy
Specialty                                                                  Cerebral Palsy Team
Service, which                                                             Craniofacial/Orofacial
one                                                                        Craniofacial/Orofacial Interdisciplinary
                                                                           Cystic Fibrosis
                                                                           Dental
                                                                           Endocrine
                                                                           ENT
                                                                           ENT/SNHL
                                                                           Feeding
                                                                           Gastroenterology
                                                                           Genetics
                                                                           Hematology
                                                                           Metabolic
                                                                           Metabolic Interdisciplinary
                                                                           MM Orthopedic
                                                                           MM Planning Interdisciplinary
                                                                           Nephrology
                                                                           Neurocutaneous
                                                                           Neurofibromatosis
                                                                           Neurology
                                                                           Neuromuscular
                                                                           Neurosurgery
                                                                           Nutrition
                                                                           Ophthalmology
                                                                           Orthopedic Surgery
                                                                           Orthodontia
                                                                           Orthopedics-foot/ankle
              Clinic/services from which referral                          Orthopedics-general
              originates. Use drop-down list to select     Drop-Down       Orthopedics-amputee
              clinic                                       List            Orthopedics-hand
Approved/                                                                  Approved
Denied        Whether or not referral meets criteria for                   Denied
              approval. Use drop-down list.
Date of
Scheduled     Scheduled date of appointment,
Appointment   regareless of whether or not the member
              completed the visit                     mm/dd/yyyy           Valid Date
Days from
Referral to
Sch.
Appointment   Number of days from referral to              calculated
              scheduled appointment                        field           Numerioc Field.




                                                                  Page 4
Field Name      Description                              Data Type      Values
                                                                        Audiology
Specialty                                                               Cardiac
Service                                                                 Cerebral Palsy Team
Referred To                                                             Craniofacial/Orofacial Interdisciplinary
                                                                        Cystic Fibrosis
                                                                        Dental
                                                                        Endocrine
                                                                        ENT/SNHL
                                                                        Feeding
                                                                        Gastroenterology
                                                                        Genetics
                                                                        Hematology
                                                                        Metabolic
                                                                        Metabolic Interdisciplinary
                                                                        MM Orthopedic
                                                                        MM Planning Interdisciplinary
                                                                        Nephrology
                                                                        Neurocutaneous
                                                                        Neurofibromatosis
                                                                        Neurology
                                                                        Neuromuscular
                                                                        Neurosurgery
                                                                        Nutrition
                                                                        Ophthalmology
                                                                        Orthopedic Surgery
                                                                        Orthodontia
                                                                        Orthopedics-foot/ankle
                                                                        Orthopedics-general
                                                                        Orthopedics-amputee
                                                                        Orthopedics-hand
                Clinic/services in which member has                     Orthopedics-cerebral palsy
                scheduled visit. Use drop-down list to   Drop-Down      Orthopedics-scoliosis
                select clinic                            List           Orthotic/Prosthetic
45 day Exempt                                                           Request of Member
                                                                        Already been seen by Specialist/ Specialty
                                                                        Member Requested Specific Specialist
                                                                        Physician's Request

Place of                                                                CRS Clinic Phoenix
Service                                                                 CRS Clinic Tucson
                                                                        CRS Clinic Flagstaff
                                                                        CRS Clinic Yuma
                                                                        Provider Office
                                                                        Phoenix Outreach
                                                                        Tucson Outreach
                                                         Drop-Down      Flagstaff Outreach
                Location of service delivery             List
Comments                                                 Text
Keyed By      Initials of staff member entering          Text
Keyed Date    Date of record entry                       mm/dd/yyyy     Valid Date
Date Received
at CRSA
              Date report received by CRSA               mm/dd/yyyy     Valid Date



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