Download GCHP Care Management referral form

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:
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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