Enhanced Case Management (ECM) Eligibility Form
The Enhanced Case Management (ECM) program is designed for ONLY Central California Alliance for Health (CCAH) eligible members up to the age of 21 years of age. The program provides case management support to help families navigate the complexities for caring for medically fragile child.
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.
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: