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Referral Date:__________________ CARE MANAGEMENT REFERRAL FORM PATIENT INFORMATION Last Name: First Name: CIN: Date of Birth: Phone Number(s): City: Preferred Language: HEALTH CARE TEAM INFORMATION Referring Physician: Office Contact & Phone Number: PCP: Phone Number(s): Fax Number: Reason for Referral: Diagnosis: History of Present Condition: Current Services (if known): Has the patient or primary caregiver been informed that a CM Referral was being submitted? Yes No Comments: _______________________________________________________ __________________________________________________________________ PLEASE EMAIL COMPLETED FORM TO [email protected] OR FAX TO (855) 883-1552 SUBMITTING A CARE MANAGEMENT REFERRAL Please email or fax this referral form and any additional clinical information that may assist the Care Manager in providing services to your patient. PLEASE EMAIL COMPLETED FORM TO [email protected] OR FAX TO (855) 883-1552 Care Management General Information Gold Coast Health Plan provides RN and LCSW Care Management services for our members. Examples of members that may benefit from GCHP Care Management services may include: • • • • • • • • • • • • • • • • • • • Complex history and has complex care needs Multiple co-morbidities Prescribed more than 15 medications Member unable to navigate the health systems Member lacks understanding GCHP benefits Member needs linkage with community resources There are barriers to care Unsafe living conditions Member does not have a caregiver/support system/lives alone Member unable to perform ADL’s and IADLs safely, with or without assistance There have been 3 or more hospital admissions in the past 6 months Expectation that the member may be readmitted to the hospital within 30 days There have been more than 3 ER visits in the past 6 months Member exhibits depression, anxiety, or has a psychological comorbidity Current DME or assistive device is not appropriate Transplants Children who do not qualify for CCS coverage but have any of the above qualifiers High Risk obstetrical members 35 weeks and below Cases that do not meet any of the above criteria but are of such intensity they warrant clinical care management and scrutiny