Get Case Management Referral Form
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How to fill out the Case Management Referral Form online
Filling out the Case Management Referral Form online can streamline the process of referring individuals for case management services. This guide will provide you with clear and concise instructions on each section of the form to ensure a smooth completion.
Follow the steps to complete the Case Management Referral Form effortlessly.
- Click the ‘Get Form’ button to access the form and open it in your designated document editor.
- In the 'Referred By' section, enter your name and title to identify who is making the referral.
- Provide your phone number to ensure that the case management team can reach you for any necessary follow-up.
- In the 'Member’s Name' field, fill in the full name of the individual being referred for case management services.
- Enter the 'Member’s Identification Number' to facilitate clear identification within the system.
- Include any suffix associated with the member's name, such as 'Jr.' or 'Sr.', if applicable.
- Specify the 'Line of Business' to clarify the context of the membership related to the referral.
- For effective communication, provide the 'Member Contact Name & Number' so that the case management team can reach the member directly.
- If known, enter the name and contact number of the member's doctor to facilitate coordination of care.
- Detail the 'Diagnosis & Reason for Case Management Referral' to give context to the referral and highlight the member's needs.
- Describe the 'Projected Outcome from Case Management' to set expectations for the referral process.
- Review the completed form for accuracy. Once satisfied, you can save changes, download, print, or share the form as needed.
- Finally, submit the completed form by faxing it to 1-877-468-7377 as instructed at the end of the form.
Get started on completing your referral form online to ensure timely support and services.
A thorough Case Management Referral Form should include the patient's full name, contact information, and a detailed account of their medical history. Also, document the reason for the referral and any specific requests you have for the receiving provider. Providing comprehensive information ensures a smooth transition of care.
Fill Case Management Referral Form
Has the patient agreed to receive an outreach call? Would you like to receive a call from a CIGNA case management team member to discuss your patient"s case? Date of Birth: Address: Phone Number: Additional Contact: REFERRAL SOURCE INFORMATION:. Date of Birth: Age: Preferred Language: English. Please fax this form to . Date: Are medical records attached to this referral? Submitting a Case Management Referral: Please fax this referral form and any additional clinical information to: . Referring Party Information. Name: Title: Phone: Fax: Email: Referral Date: Was member or authorized representative informed of this referral? For referrals to Care Management (CM) Services, including Complex Case Management and Care.
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