Get County To County

This guide provides step-by-step instructions for completing the County To County form, designed for transferring mental health targeted case management cases. Whether you are transferring cases between counties, to a tribal agency, or community providers, this guide supports you in filling out the form accurately and efficiently.

Follow the steps to complete the County To County form effectively:

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Enter today's date at the top of the form to indicate when the transfer is initiated.
3. Fill in the 'To' and 'From' sections by selecting the appropriate entities involved in the transfer, such as health plan, county, community provider, or tribal agency.
4. Provide the details of the current mental health targeted case manager, including their phone number and fax number.
5. Input the date of birth of the member or client to provide relevant personal information.
6. State the reason for the transfer clearly in the designated section.
7. Complete the member or client information section, including name, PMI number, parent or guardian details (if applicable), and home address.
8. If there’s a different mailing address, ensure to provide that information as well.
9. Describe the current issues faced by the client by checking the appropriate boxes that apply to their situation.
10. Indicate whether the member or client directs their own care. If not, provide the name and contact information of the responsible person.
11. Complete the representative payee or authorized representative section if applicable.
12. List any special needs or additional information regarding language needs and court involvement if necessary.
13. Finally, provide the contact details for primary care, psychiatrist, and care coordinator.
14. Once all fields are filled, save your changes, and you may choose to download, print, or share the completed form.

Complete and submit your documents online to ensure proper and timely transfers.