6300 RFP for TPA Attachment J DOC Health Referral Outside Agency.docx
DOCX document 83 KB Posted
- Solicitation number
- S-29100-00011086
- Issued by
- Marion County, Oregon
About this file
This document is an Attachment J - Health Referral Outside Agency form for a Request for Proposal (RFP) for Third Party Administrator and Provider Network Services for Off-Site Healthcare, RFP #291-####-## (DOC ####), issued by the Oregon Department of Corrections. The form outlines the process for referring inmates to outside medical, dental, or optical providers, including pertinent patient information, diagnosis or reason for referral, chronic conditions, special equipment needs, and authorization requirements. The RFP is seeking a Third Party Administrator to manage the provider network and off-site healthcare services for the Oregon Department of Corrections.
The form also includes a post-consult section for the Department of Corrections to approve or deny the order, along with any additional comments. Pricing terms, set asides, incumbent information, and funding sources are not included in this document, as it is focused on the medical referral process and requirements.
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Text version
ATTACHMENT J
HEALTH REFERRAL OUTSIDE AGENCY
| TO: | Appt. Date: | Time | Contact Provider |
| Institution Approval: | N/A | TLC |
Phone:
FAX:
Diagnosis or Reason for Referral: Routine (1-4 Weeks) Priority (1-3 Days) Stat (Today)
Pertinent History:
Chronic Conditions:
RFP S-29100-00011086 - Third Party Administrator and Provider Network Services for Off-Site Healthcare Att. J
RFP #291-####-## (DOC ####) – TPA for Off-Site Healthcare Reviewed by DOC esm MM/DD/YYYY - Final
Special Equipment: Wheelchair
O2 _
Other
| Allergies: | Data to be sent with patient: | ||||
| Lab | X-Ray | Chart Note | Dr. Orders | MAR | Other |
Specific Service Requested:
| MEDICAL | DENTAL | OPTICAL |
| Consultation Only | Treatment Only | Lab, X-Ray, Special Procedure |
| Consultation and Surgical Treatment | Emergency Care |
If not marked, any additional x-ray, lab, surgical, or other special procedure requires additional authorization from referring institution healthcare services.
Please send the invoice for today’s services to:
Name:
SID #:
DOB:
Group ODOC Institution
(TPA name) (TPA address)
Please write today’s diagnosis and recommendations on the reverse side.
Thank you for your interest in our patient. If you have Date Form Prepared: any concerns with this patient, please contact us. Form Prepared By:
Provider’s Returning Information Diagnosis and Findings:
Provider’s Recommendations / Orders (Do not mention any follow-up dates or times to the AIC for security reasons.) :
Provider’s Signature:
Date
Please remember to send or FAX a copy of your written report to the referring Physician.
| POST-CONSULT DOC COMMENT SECTION (Institution Use | |
| Only) | _ |
· Order Approved
· Order Denied
· To TLC
Comments:
ODOC Provider Date
File details come from the government source that posted it. Updated .