Get Community Care Collaborative Case Management Referral Form 2016-2026

Filling out the Community Care Collaborative Case Management Referral Form online is essential for facilitating effective case management services. This guide will provide step-by-step instructions to help you complete the form with confidence and accuracy.

Follow the steps to complete your referral form online.

1. Click the ‘Get Form’ button to access the Community Care Collaborative Case Management Referral Form and open it in your preferred online editor.
2. Provide your referral source information by entering the referral date, referral name, and selecting the appropriate referral source from the options: Provider, Member/Relative, UM, Community Agency, or Other. Ensure to include the phone number and fax number of the referral source.
3. Fill in the MAP member information by entering the member's name, date of birth, gender, MAP ID number, home address, language preference, and contact numbers (home, cell, work, and other).
4. Describe the reason for the referral by detailing the need for case management. Include any relevant information regarding the member's condition or circumstances. Additionally, list other diagnoses affecting the member and specify if other providers are involved in care by selecting 'Yes' or 'No' and naming involved providers if applicable.
5. Indicate the priority status of the referral by selecting either 'Urgent' for needs that require contact within 2 working days or 'Standard' for contact needed within 7 working days.
6. After completing all sections of the form, ensure to save your changes. You may also choose to download, print, or share the form as needed.

Ready to complete your referral? Start filling out the Community Care Collaborative Case Management Referral Form online today.