Complex Case Management Referral Form

Complex Case Management Referral Form
As a partner provider caring for GHC-SCW patients, you may identify members who could benefit from Complex Case Management. With Complex Case Management (CCM), a RN or SW case manager performs an assessment and provides education, coordination of resources, and ongoing communication between the member and provider to facilitate quality care and individual treatment plans.

Potential Case Management members must live in the state of Wisconsin and have GHC-SCW insurance (commercial or BadgerCare Plus) as their primary payor. Members who have Medicare A&B as Primary Insurance do not qualify for GHC-SCW Case Management.

To qualify for complex case management, members must meet one of the following criteria:
- Have five or more chronic health conditions requiring specialty care.
- Are struggling with alcohol, opioids or other recreational drugs.
- If over 18 years old, have had a recent psychiatric admission and struggle with other health conditions.
- If under 18 years old and have been admitted recently for psychiatric reasons.
Referral Source*

Provider OfficeOther
Member Information
Member Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Referring Source
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Reason for Referral (Please Be Specific)*
Should be Empty: