Bridge to Care - Enhanced Care Management (ECM) Program
Referral Form
Date of referral
-
Month
-
Day
Year
Date
Referral source
*
Please Select
Medical Provider
Behavioral Health Provider
Community Support Provider
Self
Family Member
Other Representative
If other representative, please specify
Contact person
*
First Name
Last Name
Contact person's phone number
*
Please enter a valid phone number.
Person Being Referred
Name
*
First Name
Last Name
Phone number
Please enter a valid phone number.
Email
example@example.com
Date of birth
-
Month
-
Day
Year
Age
Gender
Please Select
Male
Female
Non-Binary
Prefer not to say
Preferred pronouns
Please Select
he/him
she/her
they/them
Is the individual a resident of San Diego County?
*
Yes
No
Unknown
Insurance/Payor Information
Is the individual a Medi-Cal beneficiary?
*
Yes
No
Unknown
Medi-Cal Benefits Identification Card (BIC) ID Number:
Managed Care Plan (MCP) / Health Plan
*
Blue Shield Promise Health Plan
Molina Healthcare
Kaiser Permanente
Other
Unknown
If other, please specify:
IF THE INDIVIDUAL IS NOT A SAN DIEGO COUNTY RESIDENT AND A MEDI-CAL BENEFICIARY, STOP. THIS INDIVIDUAL IS NOT ELIGIBLE TO PARTICPATE IN FUNDAMENTAL HEALTH’S BRIDGE TO CARE PROGRAM.
Living situation
Lives alone
Lives with family
Lives with friends
Assisted living
Unsheltered
Other
If other, please specify:
Address
Street Address
Street Address Line 2
City
California
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Preferred language
Interpreter needed?
*
Yes
No
Unknown
Area(s) of Concern
Eligibility for ECM requires that the individual meet at least one of the following categories. Within each category, additional criteria may apply. Checking one or more boxes will help determine initial eligibility for ECM.
Adults (21 years and older):
Experiencing homelessness (adults without dependent children/youth) and have at least one complex health need
At risk for avoidable hospital or emergency department utilization
Serious mental health and/or substance use disorder needs
Living in the community and at risk for long-term care institutionalization due to unmet care needs and social/environmental challenges
Nursing facility resident transitioning to the community
Children & Youth (under 21 years):
Experiencing homelessness (homeless families or unaccompanied children/youth)
At risk for avoidable hospital or emergency department utilization
Serious mental health and/or substance use disorder needs
Enrolled in California Children’s Services (CCS) or CCS Whole Child Model (WCM) with additional needs beyond the CCS condition
Involved in child welfare
Health Information
Medical Diagnosis(es) (if known)
Behavioral Health Diagnosis(es) (if known)
Submit
Should be Empty: