Medical Assistance Providers and Managed Care Organizations may submit Local Health Services requests forms to the ACCU for assistance with clients in need of outreach and health-related services. (COMAR 10.09.66.03B)
Examples of recipients in need of referral include but are not limited to the following:
- Child under 2 years of age that has missed two consecutive appointments
- Child 2-21 years that has missed two consecutive appointments and is in need of treatment
- Pregnant woman that is 30 days past her appointment date
- Adult with special needs that has missed three consecutive appointments for treatment
- Non-compliance with treatment or plan of care
Providers can download then mail or fax us the completed form
