Download Referral to La Rabida Care Coordination for Children with Special

Referral to La Rabida Care Coordination for Children with Special Health Needs
La Rabida Care Coordination specializes in partnering with families of children with special health needs. La Rabida care managers
are nurses or social workers who are supported by care coordinators. They meet with members in the community, through home
and school visits, and at various health care facilities. Children with either complex medical and/or psychosocial needs, that are
difficult for their primary caregiver to navigate and provide alone, may benefit from this special CountyCare benefit.
Member Name (first and last):
DOB (mo/day/yr):
Head of Case Name:
CountyCare ID/RIN:
Other Caregiver Permitted to
Discuss Case:
Relationship to CountyCare
Member:
Phone (1):
Email:
Phone (2):
Home Address:
School Name:
Medical Home Name:
PCP Name:
Best method to contact PCP:
1. Is patient a CountyCare member?
____a. Yes ____b. No (ineligible for this service)
2. Member’s guardian aware of this referral and agreeable to services?
____a. Yes ____b. No
3. P
lease describe reasons for the referral (the child’s health condition(s) and/or other relevant circumstances:
(mark all that apply)
a. Complex health condition and/or treatment regime
b. Difficulty adhering to treatment plan: medication, appointments, etc.
c. Multiple ED visits/year
d. Multiple inpatient visits/year
e. Complex transportation needs
f. Complex social and psychosocial circumstances
g. Other: _____________________________________________________
4. Currently, how many different medications is the patient taking?
(number of meds)
5. Please list the specialist(s) the member is actively receiving services from? (Type/Name/Number)
6. P
lease provide a name and contact number for the La Rabida Care Coordinator to contact you regarding
the member/referral.
a. Contact Name:
b. Contact Number:
7. Please provide additional comments if necessary: (Free Text)
Confidentiality Fax this Completed Form to La Rabida Care Coordination Intake @ 773-363-6773