245D Referral Form - Opportunity Community Services Inc. - wordpress-opportunitycommunityservices.com

Referral: NPI # A567430300

Person Served Information

NPI or UMPI for ILS and IHS is A567430300. The service code for ILS is H2032 with a modifier of TF and the service code for IHS with Training is H2014 with modifies of UC and U3

Please provide in the Service Agreement the IHS Remote Billing Code H2014.UC.U3.U4 for IHS w/training and remote services. Remote services are required support we provide and will need to be able to bill for that.

Employment services Exploration: T2019 U2

Employment Services Development: T2019 U3

Employment Services Support T2019 U9 Individual Groups T2019HQ

Please Specify the services being requested with referral

IHS with Training

and/or Employment Services

Member Name

Date of Birth

PMI Number

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Please provide a working telephone number we can reach your member at.

Collateral Name

Ex: Family, Friend, Guardian, Rep Payee

Collateral Phone

Relationship

Collateral Name

Ex: Family, Friend, Guardian, Rep Payee

Collateral Phone

Relationship

Waiver CM and Type

Phone

CFR

County Case Number

Team Number

Diagnosis and Codes

Known Allergies

County CM Signature

First Last

Date

Please note any other details, behaviors, or known potential barriers/challenges.

Goals

Hours Approved

Note if Client Spend Down

Yes

Documents To Submit

Max. file size: 40 MB.

For referral: Please Note that a CSSP with OCS listed in the provider summary section with the specific service listed that we are providing is required for the referral process and a Face Sheet is now required with all referrals.

Documents Submitted

CSP

CSSP

Face Sheet

MN CHOICES Assessment

We thank you for the referral and we look forward to working with you!

Please note: Services will start once we have received a Service Agreement or confirmation that a Service Agreement has been submitted. Also, we are located in Oakdale, MN. Range of traveling is no more than 30 miles from our office location and maximum of 35 minutes commute. Services will be provided in three hour or more increments on a consistent, scheduled basis. Due to mileage reimbursement factors, we can’t provide services for less than 3 hours a week.

We are seeking clients who strongly want to use our services on a consistent basis and aren’t inclined to cancel weekly.

Also, please note that we can’t accept individuals with a spenddown unless they have a rep payee or other accountability measures for making payments.

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