Part 2, Chapter 3:  Manual Exhibit 2-3-A

THIS FORM (Pages 1-2) IS UTILIZED BY SOME AREAS.  OTHER AREAS ARE UTILIZING THE REFERRED CARE INFORMATION SYSTEM (RCIS) ALTERNATE RESOURCE REFERRAL FORM (Pages 3-5) PROGRAMMED INTO THE RESOURCE AND PATIENT MANAGEMENT SYSTEM (RPMS).

WRITTEN NOTICE

PATIENT REQUIREMENT FOR APPLICATION TO ALTERNATE RESOURCES

Date:____________________

TO: ____________________ Name and Address of Patient
(Use the Parent’s or Guardian’s Name and Address if the patient is a minor)

PATIENTS NAME:
TRIBE:
DATE OF SERVICE: PROVIDER:
ESTIMATED AMOUNT OF CLAIM:

The information that has been provided to the Contract Health Service (CHS) office indicates that you may qualify for an alternate resource.  Pursuant to the Indian Health Service (IHS) regulations, 42 Code of Federal Regulations, Chapter 1, Subchapter M, Part 136, Subpart C, §136.24 (attached), you are required to make a good faith effort to complete an application for alternate resources.  You must provide this facility with a copy of the alternate resource program’s eligibility determination.

THE APPLICATION PROCESS REQUIRES YOU TO DO THE FOLLOWING:

1. You must contact _____(Cite the Alternate Resource here)_____to schedule an appointment to complete an application.  It is very important that you keep your scheduled appointment.

2. You will need to bring the following documentation with you to your appointment:

   ______________________________________________________________________
   ______________________________________________________________________
   

   You might also have to provide the alternate resource program with additional documentation specifically requested prior to or during your appointment.

3. The CHS office will provide transportation for you to attend your scheduled appointment.  Please contact (Name and Phone No.) for more information.

IF YOU ARE UNABLE TO APPLY FOR AN ALTERNATE RESOURCE OR ARE HAVING DIFFICULTY APPLYING, THE CHS OFFICE IS AVAILABLE TO ASSIST YOU.  PLEASE CONTACT (Name and Phone No.) FOR ASSISTANCE.  IF AN ALTERNATE RESOURCE APPLICATION IS NOT COMPLETED, OR IF YOU DO NOT CONTACT THE CHS OFFICE FOR ASSISTANCE IN COMPLETING AN APPLICATION, WITHIN 30 DAYS OF THE DATE OF THIS NOTICE, A CHS DENIAL LETTER WILL BE ISSUED.

Sincerely,
Chief Executive Officer

Attachment

Manual Exhibit 2-3-A

Referred Care Information System

The new Indian Health Service (IHS) Referred Care Information System (RCIS) is a group of programs to assist with the clinical and administrative management of all referred care, including in-house referrals, referrals to other IHS facilities, and referrals to outside contract providers.  The system is designed to automate the referral process within a facility.  In so doing, essential information is gathered that provides timely and accurate referral data on individuals and groups of patients for the key clinical and administrative managers at care delivery sites, IHS areas, and IHS Headquarters.  The RCIS worksheet which is completed by hand is shown on the next page.

Manual Exhibit 2-3-A

Admission Dare/Appointment Date:___________________________
Duration (End Date, Time Period, Number of Visits):_________________________
Purpose of Referral (include specific diagnosis and procedures requested):______________
Pertinent Medical History, Examination, and Lab Data:___________________________________

Additional Medical Information Attached Yes____ No ____

Diagnostic Category

____ Cardiovascular Disorders
____ Cerebrovascular
____ Congenital Anomalies
____ Dental and Oral, Surgical Disorders
____ Dermatologic Disorders
____ Endocrine, Nutritional, Metabolic and Immunological Disorders ____ Ophthalmological Disorders
____ Female Breast and Genital Tract Disorders
____ Hematological Disorders
____ Infectious and Parasitic Diseases
____ Injuries and Poisonings
____ Male Genital Organ Disorders
____ Mental Disorders
____ Musculoskeletal and Connective tissue Disorders
____ Neoplasms
____ Nephrological and Urological Disorders (kidney, ureter, bladder, and urethra)
____ Neurological Disorders
____ Obstetrical Care
____ Other Parental Conditions
____ Other Symptoms, Signs, and Ill-Defined Conditions
____ Other Vascular Disorders
____ Otolaryngological Disorders
____ Preventive Health Care (Immunizations, well child care, etc.)
____ Respiratory Disorders

Procedures Category:

Medical Priority:________ Potential High Cost Case Yes____ No ____ Diagnostic Imaging:________

Review/Approval by CHS/Managed Care Committee:

____ Evaluation and/or Management
____ Nonsurgical Procedures
____ Operations/Surgery
____ Pathology and Laboratory
____ Purchase order issued
____ Payment not Authorized
____ To be determined

______________________________________________________________________
Signature:    Date

______________________________________________________________________
Referring Facility:  Referring Provider Signature: Date

______________________________________________________________________
Patient Identification:  Patient Address and Phone

Referral for Contract Professional Services

Patient Name: Joe Brown
SSN: 000-00-0000
Address: 777 N. 33rd St.    ID NUMBER: 000000
SEX: Female
DOS: May 10, 1975

Referred to:

St. Joseph's Hospital-Tucson (602-296-3211)
P.O. Box 12069-350 N Wilmont
Tucson, Arizona 85732 00Q0000000000

Outpatient Services
# of Outpatient Visits: 9
Appointment Date: March 20, 1996
Expected Ending Date: Dec 01, 1996

Purpose/Services Requested:  Routine Prenatal Care

Additional Medical Information Attached:  Not Documented by Provider

Purpose/Services Requested:  Routine Prenatal Care

Additional Medical Information Attached:

If you have any questions concerning this referral, please contact:

Sells Hospital/Clinic (contact John Smith)
P.O. Box 548
Sells, Arizona 85634 (phone: (520) 295-2533)

Referring Provider: Griffith, Stanley P.

Records indicate patient has no third-party coverage for this service date.

[Customized, site-specific text for this referral type displays here.]

OR

The standard text verbiage (below) distributed with package

__________________________ CHS Supervisor

Referral Type

In-House
IHS
Other
CHS

Test Verbiage

No verbiage available with package
No verbiage available with package
Patient is responsible for payment of services

CHS Approval Status=Pending

CHS Funds are not authorized because we do not have adequate information to make that determination.  The patient (and any alternative resources to which he/she is entitled) is responsible for this bill and has been so informed.  If CHS funding is subsequently authorized, the conditions below will apply:

APPROVED_____________CHS Funds are authorized as specified above, subject to the conditions below. DISAPPROVED__________CHS Funds are NOT AUTHORIZED.  The patient (and any alternative resources to which he/she is entitled) is responsible for this bill and has so been informed.