Attachment 12 Referral Instructions.DOC

CA-16 Referral Instructions Referral to Contractor’s Occupational Health Clinic.

Patient information:

Name of Employee: ________________________________________________________

The nurse at this satellite clinic has determined that you should see a doctor for further treatment or diagnosis. Because of our desire to arrange prompt medical attention for you, you are being referred to the ___________________ (name of Contractor medical facility) facility for further evaluation and assessment. Generally, the cost of this assessment and evaluation is covered by our contract agreement with the Center Medical Provider. If treatment is necessary beyond the services covered by our agreement and these treatments are directly related to a compensable injury, the Center Medical Provider will provide additional service and request reimbursement through the Federal Workers Compensation System. Present the enclosed CA-16 (Authorization For Examination And/Or Treatment) to the Clinic if you agree to permit the Center Medical Provider to provide this additional treatment.

Medical Provider Information:

Services provided which do not exceed the contract agreement should be charged under the provisions of the contract. Should this patient need service/treatment beyond that covered in the contract, and for compensable injuries:

1. Advise the patient that further treatment is needed and will be provided as compensation reimbursable service. The patient has the right to seek a different provider for these services.

2. If Contractor is providing services beyond the contract, complete the CA-16 and the DSCC Form 1157. When a CA-16 is used, a CA-20 should NOT be completed. Fax the completed CA-16 to (614) 693-1569, along with this completed document, the DSCC 1157, and the list of contract services (CLIN Sheet) which were provided. Send the originals, and applicable billing (for services needed beyond those covered by the contract) to the Environmental, Safety & Health Office, DES-CE, P.O. Box 3990; Columbus, OH 43218-3990; phone (614) 692-3964. The documents will be forwarded to the appropriate parties for processing.

OR

3. If referring the patient to another medical provider, including physical therapy, complete the remainder of this document and fax it to (614) 693-1569, along with the completed DSCC 1157 and a list of contract services (CLIN Sheet) which were provided. Patient should take the CA-16 to the referred medical provider.

This referral made by (Nurse) __________________________________________.

Authorization received from Environmental, Safety & Health on ______________________ from

Name and telephone number of medical service provider that this employee is being referred to:

ATTACHMENT 12