Provider Forms and References

Provider Forms

• Lock-In Referral Form / Medical Referral Form for Restricted Participants  
• New Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Missed Appointment Process 
• Pregnancy Notification Form
• Request for a Change of Primary Care Provider (PCP) Paper Fax Form

State of Missouri Department of Social Services Forms

• Acknowledgement of Receipt of Hysterectomy Information 
• Risk Appraisal for Pregnant Women
  
• Sterilization Consent Form

References

• Baby Blocks Provider Guide - UnitedHealthcare Community Plan of Missouri
• Care Provider Quick Reference Guide - UnitedHealthcare Community Plan of Missouri 
• Healthy Children and Youth/Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Billing and Coding Guide
  
• Interpreter Services
• Medical Facility Transportation Resource Guide
• Rural Health Clinic Billing Guidelines