Care Management Referral Form
Date Referral Submitted
-
Month
-
Day
Year
Date
Name of Person Submitting Referral
*
First Name
Last Name
Organization (if applicable)
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Member information
Does Member have primary MediCare coverage?
Yes
No (Explain)
Member Name
*
First Name
Last Name
Parent/Guardian Name (If Minior)
Member ID
Date of Birth:
*
-
Month
-
Day
Year
Date
Primary Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone:
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Language:
Primary Diagnosis/Conditions:
Asthma
CAD
CHF
COPD
Cystic fibrosis
Diabetes
ESRD
HTN
Transplant
Substance use
Mild-mod behavioral health diagnosis
Sickle Cell
Other
Admission History (select all apply):
2 hospitalizations in 12 months
3 ER visits in last 12 months
ER visits within last 7 days
Readmitted to hospital within past 30 days
Discharged from hospital within last 7 days
Last Admit/ER date
-
Month
-
Day
Year
Date
Why are you referring to CM? (select all that apply and explain)
Difficulty accessing medical specialty care
Difficulty accessing behavioral health specialty care
Difficulty managing medical conditions
Difficulty getting medications (include name(s) of medication in below text box)
Need support with social drivers of health
Need support with transition between care settings
Other
List of medications
Submit
Should be Empty: