"Patient Referral Form - Ky-Moms Maternal Assistance Towards Recovery (Matr)" - Kentucky

Patient Referral Form - Ky-Moms Maternal Assistance Towards Recovery (Matr) is a legal document that was released by the Kentucky Department for Behavioral Health, Developmental and Intellectual Disabilities - a government authority operating within Kentucky.

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KY-Moms
Maternal Assistance
Towards Recovery (MATR)
Patient Referral Form
Referral Guidelines
1.
To refer a potential pregnant patient or a patient no more than 60 days post-partum, please complete this form and return it,
along with a copy of the release of information form and the substance use screening tool used (e.g., PN-2*, PT-1, ACH-94,
ACH-282, H&P 13, H&P 14, HCV-2, etc.) to determine eligibility, to the designated KIDS NOW Plus mailbox/drop box within
the Health Department/Medical Office. (*PN-2 Preferred)
2.
The patient you refer will be contacted by a KY-Moms MATR Prevention Specialist or Case Manager within 48-hours of receipt
of Referral form.
3.
Only one referral per pregnancy, per patient can be made. If a patient is referred by more than one medical provider, the first
referral received will be the one accepted.
4. Please attach a patient signed Release of Information form.
Patient Information
Date of Referral:
Patient Name:
Preferred contact
Patient Address:
Method:
#:
(Email/Text/Phone)
Email:
Referral Information
Please circle
patient’s current status:
Pregnant
Post-Partum
Diagnosis
Code:
Due Date/
Delivery Date:
Medicaid #:
YES / NO
Does patient currently present with substance use RISK FACTORS during pregnancy?
YES / NO
Does patient currently present with SUBSTANCE USE concerns during pregnancy?
Referring Doctor (Printed): __________________________________________
Signature: _______________________________________________________
Name of Referring Agency: __________________________________________________________________________
For KY-Moms MATR Use Only
Date Received:
Contacted?
Prevention
Education
Case Management
Appointment?
Appointment?
KY-Moms
Maternal Assistance
Towards Recovery (MATR)
Patient Referral Form
Referral Guidelines
1.
To refer a potential pregnant patient or a patient no more than 60 days post-partum, please complete this form and return it,
along with a copy of the release of information form and the substance use screening tool used (e.g., PN-2*, PT-1, ACH-94,
ACH-282, H&P 13, H&P 14, HCV-2, etc.) to determine eligibility, to the designated KIDS NOW Plus mailbox/drop box within
the Health Department/Medical Office. (*PN-2 Preferred)
2.
The patient you refer will be contacted by a KY-Moms MATR Prevention Specialist or Case Manager within 48-hours of receipt
of Referral form.
3.
Only one referral per pregnancy, per patient can be made. If a patient is referred by more than one medical provider, the first
referral received will be the one accepted.
4. Please attach a patient signed Release of Information form.
Patient Information
Date of Referral:
Patient Name:
Preferred contact
Patient Address:
Method:
#:
(Email/Text/Phone)
Email:
Referral Information
Please circle
patient’s current status:
Pregnant
Post-Partum
Diagnosis
Code:
Due Date/
Delivery Date:
Medicaid #:
YES / NO
Does patient currently present with substance use RISK FACTORS during pregnancy?
YES / NO
Does patient currently present with SUBSTANCE USE concerns during pregnancy?
Referring Doctor (Printed): __________________________________________
Signature: _______________________________________________________
Name of Referring Agency: __________________________________________________________________________
For KY-Moms MATR Use Only
Date Received:
Contacted?
Prevention
Education
Case Management
Appointment?
Appointment?