Document 6532453

* Direct Referral Form is to be used when a Provider /
CBAS Center identifies a Member who may be
qualified to receive CBAS services.
SAMPLE - CBAS Inquiry / Request Form
Patient Name : (Name of Member being referred for CBAS eligibility
assessment)
Date :
DOB: (Birth Date of Member being referred)
Member ID # : (From the Member’s Molina Card)
(Date Referral is sent to Molina)
Line of Business :
Address: (Address of Member being referred)
(Medicare, Dual, Medi-Cal)
Phone: (Phone number of Member being referred)
Referring Provider / CBAS Center
CBAS Center Requested: (Center if known that the Member has
chosen)
Referring Provider / CBAS Phone # : (
)
Referring Provider / CBAS Name :
Referring Provider / CBAS Fax
)
#: (
Date Referred: (Date that provider referred
member to CBAS center for potential
eligibility)_________________
Referring Provider / CBAS Address :
Functional, BH, Clinical Reasons for Potential Eligibility for CBAS Services : (Attach all necessary information to
this referral if you do not have space below)
Billing Code:
Billing / Service Description:
Functional Issues / Mental Health and or Medical Diagnosis (Key reasons why the patient may qualify for CBAS services):
Functional Issues / Mental Health and or Medical Diagnosis :
(Document all know information related to why our Molina Member is appropriate to be evaluated for CBAS eligibility.)
THIS REFERRAL IS VALID FOR 30 DAYS ONLY
Please Fax the Request to: 1-800-811-4804 or if you have questions may call our Molina Utilization Management
Department at 1-800-526-8196 Ext. 126400
Rev 09/28/2012