Referral

MEMBER INFORMATION
The Department of Medical Assistance Services Community Stabilization (S9482) Referral Form
Member Name:
Name

First NameLast Name
Medicaid #:
Member Date of Birth

MonthDayYear
Date
Member Plan ID
Gender:
Member Address:
City, State, ZIP:
Member Phone #:
Parent/Guardian
Parent/Guardian Name
Phone Number (if applicable)
Please enter a valid phone number.
Rendering Provider Information
Organization Name:
Provider Phone #
Provider E-Mail:
Provider Address:
City, State, ZIP:
Provider Fax #:
Clinical Contact Name Credentials:
Clinical Contact Phone #
REASON FOR REFERRAL
Date of Discharge/anticipated discharge

MonthDayYear
Date
By my signature (below), I am attesting that 1) I have performed care coordination activities and collaborated with the Community Stabilization provider as part of my discharge planning 2) the member is in need of Community Stabilization Services as part of a comprehensive discharge plan.

Signature (actual or electronic) referring provider:
Signature

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Printed Name of referring provider
Title
Credentials (if applicable)
Date

MonthDayYear
Date
Community Stabilization Referral Form Template 09.01.2022
Should be Empty:

Member Name: