AGENCY: Department of Health. Division of Medicaid and Health Financing. Bureau of Authorization and Community Based Services

SERIES: 8135
TITLE: Referral form
DATES: 1983-
ARRANGEMENT: Chronological

DESCRIPTION: This is for clients who choose to have a primary care physician must go to that physician for all medical treatment. If the client requires treatment that the primary care physician cannot provide, this form must be completed for the treatment to be covered. This form is also used as an input document to the MMIS data system. It includes the name of the health care plan or insurer, the patient's name and date of birth, the insured's name, identification number, and group number, the name, address, and phone number of the consulting physician, the medical problem needing treatment, the services requested (assume care for disorder, surgery, etc.), the signature, and license number of the primary care physician, the date the referral was authorized, and the name, address, and telephone number of the primary care physician.

RETENTION

Retain for 8 year(s)

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

These records are in Archives' permanent custody.

APPROVED: 08/1986

FORMAT MANAGEMENT

Paper: Retain in Office for 1 year and then transfer to State Records Center. Retain in State Records Center for 7 years and then destroy.

APPRAISAL

Administrative Fiscal

This record is subject to federal audit. The audit period is three fiscal years, so the record should be kept four calendar years. The record need be kept in the office only long enough to ensure that the information was correctly input into the data system.

PRIMARY DESIGNATION

Private

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