Clone of Care Management

Care Management Referrals
Referral Type
Medicaid ID Number (CIN)
CIN has 8 characters total: 2 letters, 5 numbers, 1 letter e.g. AB12345C
I certify that the member is eligible for care management services based on the New York State Department of Health (DOH) criteria: possessing either one single qualifying condition (e.g. SMI or HIV/AIDS) or two or more chronic conditions.
Demographics
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Pronouns
Race
Ethnicity
Religion
Primary Written Language
Primary Spoken Language
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
Phone Number
Other Phone
Other Patient Details
Should be Empty:

Care Management Referrals