Get Medicaid Referral Form

QI-1 or Qualified Individual (effective February 2023): Income cannot exceed $1,661 per month for an individual. Income cannot exceed $2,239 per month for a couple. Plan First/Pregnant Women/Children (Ages 0-18):* Income after deductions cannot exceed $1,774 per month for a family of 1.

The cascading referral permits subsequent providers to refer the recipient to additional providers without a having to request a new referral.

Recipients who are proven to have abused or misused the Medicaid program may be "locked in" to one doctor and one drug store, be required to repay the Agency for misspent funds and/or may be suspended from the program for at least one year and until full restitution is made.

The cascading referral permits subsequent providers to refer the recipient to additional providers without a having to request a new referral.

Prior Authorization (approval in advance) is required for many procedures, services or supplies, including transportation. Click here for information on obtaining an Emergency PA for medications. Below are the forms used for Prior Authorization. Prior Review and Authorization Request Note: a completed form is required.

To qualify for Medicaid, applicants must meet income, age or other requirements; provide proof of income and other information, fill out forms correctly and turn in a completed application to the correct office or worker. For more help, applicants should contact 1-800-362-1504.

What do I need to do? Most specialists require a referral from your primary care provider.

Prior Authorization (approval in advance) is required for many procedures, services or supplies, including transportation. Click here for information on obtaining an Emergency PA for medications. Below are the forms used for Prior Authorization. Prior Review and Authorization Request Note: a completed form is required.