Enhanced Case Management/Infant and Family Case Management Program Eligibility Form
The Enhanced Case Management (ECM) program here at CKHC is geared towards serving CCAH eligible Children and Youth enrolled in CCS or CCS WCM or At Risk of Avoidable ED/Hospital Use between 7 months - 21 years old. The Infant and Family Case Management (IFCM) program is geared towards patients enrolled in Medi-Cal/CCAH/Private insurances and are under the age of 5 years old.
Client Name:
*
First Name
Last Name
Patient's DOB:
*
County of Residence:
*
CCAH eligible member
*
Yes
No
If yes, please include CCAH #
CCAH ID #
Primary Contact Name:
*
First Name
Last Name
Relation:
*
Contact Phone #:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Must meet one of the following criteria to be eligible for services. Please select at least one.
*
Child/Youth Enrolled in CCS or CCS WCM with Additional Needs Beyond the CCS Condition
Child/Youth At Risk of Avoidable Emergency Department/Hospital Use
Unsure
Please check all that apply to patient and other family residing in the home.
*
Homelessness/Inadequate Housing/Housing Inequality
Lack of Adequate Food/Food Insecurity
Insufficient Social Insurance or Welfare Support
Extreme Poverty/Low-Income
Child in Welfare Custody/Foster Parent(s) or Guardian(s)
Insufficient Access to Medical/Dental/Vision Care
Language Barrier? (Not Spanish):
Notes/Concerns:
Referral Made By:
*
First Name
Last Name
Contact Phone Number of Individual Making the Referral:
*
Please enter a valid phone number. Additional information may be requested.
Format: (000) 000-0000.
Email
example@example.com
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: