MED Referral to: and Basic Demographic Information Consumer Age: name: Prime #: Language: Case Manager Gender: name and email: Setting address Impairment: Vision: if different Yes No from 002N (for Impairment: Hearing: appt.): Yes No Setting type Consumer/Rep. (in-home, AFH, phone #: etc.): Setting contact Referral date: name and phone #: Have there been previous MED referrals or decisions? Yes No If yes, when? Have there been any past services approved? APD MH ODDS Are any services currently approved? APD MH ODDS Referrals must include a release of information authorizing sharing of information with Maximus for eligibility purposes. Referrals must have a current completed assessment (within the last months) and include the 002N. Contacts Name Title # Email
MED Referral to: and Basic Demographic Information Consumer name: Age: Prime #: Language: Case Manager name and email: Gender: Setting address if different from 002N (for appt.): Impairment: Vision: Yes No Impairment: Hearing: Yes No Setting type (in-home, AFH, etc.): Consumer/Rep. phone #: Setting contact name and phone #: Referral date: Have there been previous MED referrals or decisions? Yes No If yes, when? Have there been any past services approved? APD MH ODDS Are any services currently approved? APD MH ODDS Referrals must include a release of information authorizing sharing of information with Maximus for eligibility purposes. Referrals must have a current completed assessment (within the last months) and include the 002N. Contacts Name Title # Email