Serenity Enhanced Care Management Provider Referral Form
For referrals to Enhanced Care Management (ECM) Services, provider or staff should complete this referral form.
All fields marked with * are required and must be filled.
Referring Practice Name (if applicable):
Referring Provider Name (if applicable):
First Name
Last Name
Referring Provider Phone Number (if applicable):
Please enter a valid phone number.
Referring Provider Fax Number (if applicable):
Please enter a valid phone number.
Referring Provider Email Address (if applicable):
example@example.com
Member Details
Member Name
*
First Name
Last Name
Other Names the member has used
First Name
Last Name
Member Date of Birth
*
-
Month
-
Day
Year
Date
Member Medi-Cal Subscriber ID
*
Member Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Member Phone Number
*
Has the patient/member been informed that an ECM referral is being requested?
*
Yes
No
Has the patient/member indicated a preferred ECM Provider?
Yes
No
What is the primary problem/reason for the referral? (Please check all that apply)
*
Adult/Family- Experiencing Homelessness or At-Risk of Homelessness
Adult- Individuals at Risk for Avoidable ED use or Hospitalization
Adult- Individuals Transitioning from Incarceration
Adult- Pregnant or delivered baby within 12 months
Adult- Intellectual and Developmental Disabilities
Youth- Experiencing Homelessness or At-Risk of Homelessness
Youth- Individuals at Risk for Avoidable ED use or Hospitalization
Youth- Individuals Transitioning from Incarceration
Youth- Pregnant or delivered baby within 12 months
Youth- Intellectual and Developmental Disabilities
Other
If Other, please give description:
Additional Comments
Submit
Should be Empty: