Form Ef03-14040 - Provider Outreach Referral Form
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1
2TEXAS HEALTH STEPS
PROVIDER OUTREACH REFERRAL FORM
FAX: 512-533-3867
•
Complete this form and submit by fax.
•
Use only ONE FORM PER HOUSEHOLD, up to 2 patients.
•
You will receive notification once your referral is processed.
Provider Information
Date:
Provider/Clinic Name:
Contact Name:
Office Address:
City:
County:
Zip Code:
Phone Number:
Fax Number:
Provider Type:
Medical
Dental
Orthodontic
Case Management
Other:
Parent/Guardian Information
Parent/Guardian Name:
Phone Number:
Mobile Number:
Address:
City:
County:
Zip Code:
Language Preference:
English
Spanish
Other:
Patient #1 Information
Patient Name:
Date of Birth:
Medicaid ID:
Appointment Type:
THSteps Checkup
THSteps Followup
Sick Visit
Lead
Other:
Reason for referral (check all that apply)
Patient missed appointment, date:
Assistance needed scheduling appointment.
Follow-up appointment for additional lead testing.
Provide updated patient address
(Case Management Only)
Assist with transportation to appointment.
Other, see comments.
Comments:
Outreach Services Results (SSU Use Only)
Appointment scheduled; date/time:
Patient provided education about appointment etiquette.
Patient assisted with transportation to appointment.
Patient will contact provider directly.
No action taken; patient declined assistance.
No action taken; patient no longer eligible for Medicaid.
Unable to locate patient; letter mailed to patient.
Other:
Comments to Provider:
Patient #2 Information
Patient Name:
Date of Birth:
Medicaid ID:
Appointment Type:
THSteps Checkup
THSteps Followup
Sick Visit
Lead
Other:
Reason for referral (check all that apply)
Patient missed appointment, date:
Assistance needed scheduling appointment.
Follow-up appointment for additional lead testing.
Provide updated patient address
(Case Management Only)
Assist with transportation to appointment.
Other, see comments.
Comments:
Outreach Services Results (SSU Use Only)
Appointment scheduled; date/time:
Patient provided education about appointment etiquette.
Patient assisted with transportation to appointment.
Patient will contact provider directly.
No action taken; patient declined assistance.
No action taken; patient no longer eligible for Medicaid.
Unable to locate patient; letter mailed to patient.
Other:
Comments to Provider:
EF03-14040 02/2013
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Parent category: Legal