Enhanced care management referral
Please verify that the Medi-cal member has active insurance. Select the appropriate insurance.
Health Net
La Care
Molina
Date of Referral:
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referral Name & Title:
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Referral Phone Number:
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Referral email address:
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example@example.com
MEMBER INFORMATION
Member Name:
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Member Medi-cal #:
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Member DOB:
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Member Address & apt#:
Member City:
Member Zip code:
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Member phone Number:
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Please enter a valid phone number.
Format: (000) 000-0000.
Language:
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CAREGIVER NAME AND CONTACT INFORMATION
Name:
Phone/Email:
MEMBER’S POPULATION OF FOCUS *specific to Didi Hirsch – check all that apply
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POF 1.0: Adults Experiencing Homelessness
POF 1.1: Homeless Families or Unaccompanied Children/Youth Experiencing Homelessness
POF 2.0: Adults at Risk for Avoidable Hospital or ED Utilization
POF 2.1: Children/Youth at Risk for Avoidable Hospital or ED Utilization
POF 3.0: Adults with Serious Mental Health and/or Substance Use Disorder (SUD) Needs
POF 3.1: Children/Youth with Serious Mental Health and/or Substance Use Disorder (SUD) Needs
POF 5.0: Adults Living in the Community who are at Risk for LTC Institutionalization
POF 6.0: Adult Nursing Facility Residents transitioning to the Community
POF 8.0: Children/Youth Involved in Child Welfare
POF 10.0: Adults Pregnant and Postpartum Individuals At Risk for Adverse Perinatal Outcomes Must also qualify for eligibility in any other adult ECM Population of Focus
POF 10.1: Children/Youth Pregnant and Postpartum Individuals At Risk for Adverse Perinatal Outcomes Must also qualify for eligibility in any other children/youth ECM Population of Focus
Continuity of Care (COC) Only applies to members transitioning from ECM with another CA Medi-Cal heal
Complex physical, Behavioral Health Condition (Must meet one of the following conditions)
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Asthma
Dementia requiring assistance with IADLs
Chronic Kidney Disease
Diabetes (Insulin-dependent) poorly controlled
Chronic Liver Disease
History of stroke or heart attack
Chronic Obstructive Pulmonary Disease (COPD)
Hypertension (poorly controlled)
Congestive Heart Failure (CHF)
Traumatic Brain Injury (TBI)
Coronary Artery Disease
Pregnant & at risk
Post-partum
Bipolar disorder
Psychotic disorders, including schizophrenia
Major Depressive Disorder
Substance Use Disorder, please specify
Other
If Other, please note
PROVIDE DETAIL DESCRIPTION OF NEED or reason for the referral ADDITIONAL COMMENTS or information to support your referral:(i.e. PCP or support person name and contact if applicable) Consider including onset of symptoms and date of diagnosis. Include where to locate the member is unhoused.
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How did you hear about us:
Website
PCP/Doctor
Friend/Family
Current / Prior member
Training
Case Manger
Other community provider
Social Media
other:
If Other, please note
Submit
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