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Indian Health Service The Federal Health Program for American Indians and Alaska Natives


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

Written Notice, Patient Requirement for Application Alternate Resources


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:

  3. ______________________________________________________________________
    ______________________________________________________________________

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

  4. 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



Referred to (Name, Address, Phone #): Referral Type: Primary Payer:
____________________________ _____ CHS _____ IHS
____________________________ _____ IHS (another facility) _____ Medicare
____________________________ _____Other _____ Medicaid
____________________________ _____ Inpatient _____ Private
____________________________ _____ Outpatient _____ Patient
____________________________ _____ _____ VA
____________________________ _____ _____ Other


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



Procedures Category:

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


Review/Approval by CHS/Managed Care Committee:

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


__________________________________________________________________
Signature
________________________________________
Date


__________________________________________________________________
Referring Facility
________________________________________
Referring Provider Signature    Date


__________________________________________________________________
Patient Identification
________________________________________
Patient Address and Phone



Referral for Contract Professional Services

Patient Identification, Address, Phone Number

Patient Name: Joe Brown ID NUMBER  000000
SSN: 000-00-0000 SEX:  FEMALE
Address: 777 N. 33rd St. 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: Mar 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 Test Verbiage
In-house No Verbiage available with package
IHS No verbiage available with package
Other Patient is responsible for payment of services
CHS   


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.


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