Get Case Management Request Form - Driscoll Health Plan

Filling out the Case Management Request Form for the Driscoll Health Plan online is a straightforward process designed to gather essential information for case management and health education needs. This guide will assist you in completing each section effectively to ensure your submission is complete and accurate.

Follow the steps to fill out the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the designated editor.
2. Provide the provider information by entering the provider name, contact name, phone number, National Provider Identifier (NPI), and Taxpayer Identification Number (TPI) in the respective fields.
3. Enter the client or member information, including their name, Medicaid/CHIP ID number, and phone number. You may also include an alternate phone number for additional contact options.
4. Indicate the reason for the referral due to office issues by checking the appropriate boxes, such as treatment plan adherence, abuse of the emergency room, frequent missed appointments, or other applicable reasons.
5. Specify the case management or health education needs by selecting all relevant options provided, including but not limited to asthma, childhood illness, and behavioral psych disorder.
6. If the referral is related to high-risk pregnancy, complete the relevant section by selecting the reasons for referral, such as non-compliance with prenatal care or missed appointments.
7. Include any additional referral comments or notes that may be necessary for the case management team.
8. Once all sections are filled out, review the information for accuracy and completeness. You can then save changes, download, print, or share the form as needed.

Complete your Case Management Request Form online and ensure your request is processed smoothly.