Behavioral Health Condition Management Program Referral Form

Referrals for

Behavioral Health Condition Management
Complex Case Management

Clinical Referrer First Name: *

Clinical Referrer Last Name: *

Clinical Referrer Phone: *

Clinical Referrer Email: *

Referral Program: *

Referral Program (if other *):

Date Sent: (MM/DD/YYYY) *

Behavioral Health Condition Management criteria (with co-occurring medical condition; ages 18+):

Positive PHQ-2

Member self-identifies as depressed Warm Referral Phone 800-424-6071

Behavioral Health Complex Case Management criteria:

Member with three (3) or more known prior inpatient admissions at any time

Member ages 18-26 with one (1) substance-abuse related admission

Pregnant women who abuse substances

Children age 12 and under who are hospitalized

Member with one (1) or more inpatient admissions for eating disorder

Children of any age with one inpatient admission and a diagnosis of autism spectrum disorder

Member with 25 inpatient days in a rolling 12-month period

Referral from Care Manager as a result of targeted risk assessment

Other, i.e. customer specific:

Member First Name: *

Member Last Name: *

Member Phone: *

Date of Birth: (MM/DD/YYYY) *

Member Email Address:

Subscriber ID: *

(Do not enter any hyphens (-) for Subscriber ID)

Best Time to Contact/Time Zone:

Indicate if this is an Out of State Referral or CA Based Referral: *
CA Out of State
(Only eligible plans for Out of State CCM = ASO/Shared Advantage)

Medical Diagnoses: *

If Medical Diagnosis is ( OTHER* ), please specify:

Additional Clinical Information:

Please notate special requests/preferences:

Provider First Name:

Provider Last Name:

Provider Phone:

Medication:

Comments: