Enhanced Case Management (ECM) Eligibility Form
The Enhanced Case Management (ECM) program is designed for Central California Alliance for Health (CCAH) eligible members between 7 months and 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: