Get Cc4c Referral Form

Filling out the Cc4c Referral Form online is an essential step in accessing care coordination services for children. This guide will provide you with a clear, step-by-step approach to ensure you complete the form accurately and efficiently.

Follow the steps to complete the Cc4c Referral Form online.

1. Click ‘Get Form’ button to access the Cc4c Referral Form and open it in the designated editor.
2. Begin by entering the child's name and the referral date in the specified fields. Ensure the date is formatted as mm/dd/yyyy.
3. Next, fill in the child's date of birth and select their gender from the provided options.
4. Indicate the child's race by selecting one of the options available in the race section.
5. Provide the child’s Medicaid ID number if applicable, and indicate if the child is uninsured or has health insurance choices that include Medicaid and private insurance.
6. Answer the question about whether you have applied for Medicaid, and if yes, include the name of the private insurance company.
7. Continue by entering the parent or guardian's name, date of birth, and their primary spoken language in the home.
8. Indicate whether an interpreter is needed and fill in the address, city, zip code, and county of residence.
9. Provide home and cell phone numbers, as well as the employer's name and work phone number if applicable.
10. List the name and contact number of a relative or neighbor for emergencies.
11. Fill in the referring organization’s name, contact person, and their email and phone numbers, including whether this person is the child’s primary care provider.
12. Answer the question about whether the parent or guardian has been informed of the referral.
13. If there are specific concerns for the child, provide details in the designated section under target populations for referrals.
14. Complete the medical home referral section if applicable, including reasons for referrals not indicated earlier.
15. Review all the entered information for accuracy before completion.
16. Once you have confirmed that all information is correct, save your changes, download, print, or share the form as necessary.

Begin filling out the Cc4c Referral Form online to ensure timely access to vital services.