Uniform Referral Form
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Web A Standing Referral Is Valid For A Stated Length Of Time Up To Six Months Or A Specific Number Of Visits, Or Both, And May Be Issued Only For Specific Diagnosis.
(last, first, mi) date of birth: Payment of benefits is subject to a member’s. Yesno* if no, please notify within 24 hours first name:street. Web maryland uniform consultation referral form.
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Web primary care providers must use the maryland uniform consultation referral form (pdf) when referring medstar family choice members to specialists. Brief history, diagnosis, and test results: If another physician is referring your child, they can complete the form. Minutes if screening an individual from another area, has the home agency been consulted/notified?