Referral Form

Equipment Referral Form
Date

MonthDayYear
Date
Sales Rep *Please make sure to choose the correct rep that calls on your office*
Misty Ruhl
Brandon Meredith
Kevin Nunnally
Ashley Gilbow
Referral Source Name (Nurse, Case Manager, Aide)*

First NameLast Name
Referral Source Phone#*
Format: (000) 000-0000.
Referral Email - for your copy of this referral
example@example.com
Company You Represent & Location (Town)*
Patient Information
Patient First Name (Legal)*
Patient Last Name*
*

MaleFemale
Patient Date of Birth*

MonthDayYear
Date
Patient Height*
Patient Weight*
Patient Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Patient Address*

Street Address

Street Address Line 2 or Apartment #

CityState / Province

Postal / Zip Code
Person to speak to regarding order*
We must be able to speak to the patient and or caregiver to complete the processing of this request.
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
If we can speak to the aide regarding this order & future orders please provide aide's name & phone #
We must be able to speak to the patient and or caregiver to complete the processing of this request.
If we can speak to family regarding this order & future orders please provide name & phone(s) #
Use comment box below to list addition contact(s) for the patient
PCP Name & Phone #*
Arkansas Medicaid ID# or PASSE ID#*
Diagnosis or conditions *
**In order to qualify for incontinent supplies the patient will need a diagnosis of urinary incontinence, nocturnal enuresis, or mixed incontinence. Other qualifying conditions exist such as autism, developmental delay, cerebral palsy, ADHD, PTSD, Hirschsprung's disease, spina bifida, etc.
Does the client (patient) have difficulty getting around inside of their home due to Dizziness, Shortness of Breath, COPD or Recent Falls?

YesNo
Check all that apply - Which mobility limitations does the client (patient) face within the home?

DizzinessShortness of BreathCOPDRecent FallsUnsteady GaitOsteoarthritis of the kneesOther - List other in the comment box at the bottom
What mobility equipment does the client (patient) currently use, if any?

NoneCaneWalker/RollatorManual WheelchairScooterPower Wheelchair
Does the clients (patient) current equipment meet their needs?

Yes, their equipment meets their needs. No additional mobility equipment is needed.No, Medical Solutions will check the patients benefits for the next level equipment.
If there are mobility limitation Medical Solutions can start the process to get the mobility aid needed so the patient can complete their MRADLs accordingly. Which item would best meet their needs?

Bedside Commode (client is confined to a single room or client is confined to one level of the home with no toilet facilities on that level)CaneWalker with NO wheelsWalker with wheelsRollator (four wheels with a seat and hand brakes)Manual WheelchairScooterPower Wheelchair
Does the client (patient) have a need for a hospital bed due to Shortness of Breath, Congestive Heart Failure or COPD?

Yes, Medical Solutions will verify benefits & fax the prescription to the clients doctor.No, The client does not have a need for a hospital bed at this time.
Additional Accessories for the Hospital Bed

Manual Patient Lift (or)Trapeze BarLow Air Loss Mattress - must have active wounds on the trunk
Clients (patients) with Full Range Medicaid
Bathroom Safety Needs - Does the patient have trouble stepping into the bathtub safely or trouble standing while showering?

Yes, Medical Solutions will fax a prescription to the clients doctor for the item checked below.No
Bathroom Safety Options

Hand Held ShowerTub Transfer BenchTub Grab Bar (must have a bathtub) these are not for the wallShower Chair
Incontinence Needs - Does the client (patient) have bladder or bowel control concerns?

Yes, Medical Solutions will fax a prescription to the clients doctor for the supplies checked below.No
Incontinence Supply Options - Arkansas Medicaid allows $130.00 per month

PullupsBriefsGlovesBed PadsPanty/Underwear Liners
Which diagnosis best describes the patients need for the incontinent supplies?

Urinary Incontinence R32Fecal Incontinence R15.9Mixed Incontinence N39.46Stress Incontinence N39.3Nocturnal Enuresis N39.44
Children ages 5-20 years old - Boost - Is there a need for nutritional supplement drinks due to being underweight, ADHD/ADD or other nutritional needs?

Yes, Medical Solutions will verify benefits & fax a prescription to the clients doctor.No
All Ages - Thickener - Is there a need for thickener due to choking, swallowing difficulties, gerd or reflux?

Yes, Medical Solutions will verify benefits & fax a prescription to the clients doctor.No
Diabetic Supplies - If the client (patient)is under the age of 65 and has Arkansas Medicaid ONLY, has an Arkansas Medicaid PASSE insurance or an Arkansas Medicaid Replacement Plan we can supplies their diabetic testing supplies.

Yes, Medical Solutions will fax a prescription to the clients doctor.No
Equipment Requested:

NebulizerHospital Bed with Therapeutic MattressTrapeze BarLow Air Loss (must have active wounds on trunk)Patient Lift (manual only)Bedside CommodeStraight CaneSmall Base Quad CaneLarge Base Quad CaneWalker no wheelsWalker with wheelsRollator (Black, Red, Blue, Green) *Enter color in notes belowManual Wheelchair & cushionsScooter EvaluationPower Wheelchair Evaluation
Full Range Medicaid ONLY covered equipment:

Shower Chair (not covered by Ambetter - we suggest a transfer bench)Hand Held Shower (must have shower in bathroom)Tub Transfer BenchTub Grab Bar (not for wall -must have and use bathtub)Diapers (we do not accept Ambetter for inct)Pullups (we do not accept Ambetter for inct)Gloves (we do not accept Ambetter for inct)Bed Pads (we do not accept Ambetter for inct)Underwear Liners (panty liners) (we do not accept Ambetter for inct)Ages 5-20 Boost Liquid DrinkAges 0-99 Thick-It Thickener
Comments from care provider (optional)
Use this section to inform us of sizes needed, color preference of rollator, other applicable diagnosis or general comments.
Confirm*

I have informed the patient an appointment with their physician may be needed to discuss the equipment requested
Confirm*

I understand my physician may require an appointment to discuss the equipment requested
Confirm*

The referral source must thoroughly discuss the need for the requested equipment with the patient (prior) to completing this form. Asking the patient if they have ever had the equipment and or if they would like to receive this equipment. If the patient declines or if you have not discussed the need with the patient please do not complete this form. In the past we have attempted to deliver equipment the patient was unaware of and therefore declined at delivery.
Confirm*

I request Medical Solutions of Arkansas to obtain an order from my physician for the equipment needed above.
Assignment of Benefits
Assignment I hereby request payment of my authorized carrier to be made on my behalf to Medical Solutions of Arkansas, LLC for current and reoccurring products and services they provide me. I further authorize a copy of this agreement to be used in place of the original and any holder of information about me is authorized to release such information to Medical Solutions of Arkansas, LLC and Health Care Finance Administration and any other insurance and/or their agents to assist in determining my benefits. Release of Information I hereby authorize the holder of medical or other information about me to release to the Social Security Administration, Centers for Medicare and Medicaid Services and its intermediary’s accreditation or regulatory agencies, or to any third-party payer, as required, any information needed for this or a related health claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the party who accepts assignment. I hereby authorize and medical facility, healthcare provider or other holder of medical information pertaining to me to release this information to Medical Solutions of AR, LLC or their representatives so that Medical Solutions of AR, LLC is able to prepare claims for submission on my behalf to Medicare, Medicaid or other third-party payers. Patient Responsibility I hereby guarantee payment to Medical Solutions of AR, LLC for any and all charges not covered by this assignment and waive any and all notices and demands in the event of non-payment there under. I am aware that Medical Solutions of AR, LLC will bill me for all deductible and co-pay charges on all equipment and/or supplies that I have rented and/or purchased each month. I also agree that all rental equipment will be returned to Medical Solutions of AR, LLC in good condition exclusive of normal wear through usage. I agree to compensate Medical Solutions of AR, LLC for any loss due to misuse, lost, stolen or damaged property. I hereby certify that I have read or have had this document read to me. I understand it’s content and intent, and with my signature so execute my permission, effective as dated. I acknowledge receiving a copy of the AHS Notice of Privacy Practices.
Change of Provider Request*
My signature below serves as my notice to cancel equipment and or supplies with your company effective immediately. 

I will get all future services and supplies from: 

Medical Solutions of Arkansas 
1000 E. Matthews Ave Suite F
Jonesboro, AR 72401
Ph 1-870-910-0400
Fx 1-870-336-9600
Patient Signature **This must be signed by the patient or caregiver. This form may not be signed by home health agency staff, personal care service staff, or alike. ***Please complete this form during your home visit.*

Acknowledgement of requesting the equipment above, Assignment of Benefits, Release of Information, Patient Responsibility, Consent to Trerat and Change of Provider Request.
Date this request is effective for Change of Provider, AOB & Consent to Treat*

MonthDayYear
Date
Should be Empty:

Equipment Referral Form

Patient Information

Clients (patients) with Full Range Medicaid