Care Coordination Referral Form

Please complete as much of the form below as you are able to in order to ensure that MHA is able to follow up and provide Care Coordination services promptly upon receipt of this referral.

Date Date / MM / DD YYYY
Referring Individual's Name: Referring Individual's Name: First Last
Referring Individual's Phone Referring Individual's Phone - ### - ### ####
Referring Individual's Email
Relationship To Individual Being Referred for Care Management Services
If Other is selected please provide a description of your relationship to the person being referred for services:
Name of Individual being referred for Care Management services: Name of Individual being referred for Care Management services: First Last
Phone of Individual being referred for Care Management services: Phone of Individual being referred for Care Management services: - ### - ### ####
Email of Individual being referred for Care Management services:
Address of Individual being referred for Care Management services: Address of Individual being referred for Care Management services:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Is Referral Facing Any Housing Insecurity, Such as:

Is Referral Facing Any Housing Insecurity, Such as: Other Other
If Homeless, Where is the Best Place to Meet Referral?
Preferred Method of Contact

Preferred Method of Contact Phone Video Call In-Person
Primary Language of Individual Being Referred for Care Management Services:
Gender Pronouns of Individual Being Referred for Care Management Services:
Does the Individual being referred for Care Coordination services have Medicaid?

Does the Individual being referred for Care Coordination services have Medicaid? Yes No

Please be advised that if no, MHA has a limited Non-Medicaid caseload that is often at capacity.

If MHA is unable to accommodate your Non-Medicaid care management needs, the outreach team will refer you to an agency that can.
If yes, Managed Care Organization (MCO) Name:
If yes, enter their Medicaid ID#
If no, are they Medicaid Eligible?

If no, are they Medicaid Eligible? Yes No Unsure
Is Referral Enrolled in a HARP?

Is Referral Enrolled in a HARP? Yes No Unsure
If no, are they HARP Eligible?

If no, are they HARP Eligible? Yes No Unsure
Health Home Eligibility

2 or more Chronic Conditions or 1 Single Qualifying Serious Chronic Conditions (AIDS/HIV, Serious Mental Illness)
Major Category

Major Category Alcohol & Substance Use Disorder Mental Health Cardiovascular Disease AIDS/HIV Serious Mental Illness Other Other
Please give a brief description of any conditions selected above:
Comments

Any additional information about the individual or their circumstances that would be helpful for our Outreach Team.

Any pets in the household? Other Family members?

Any Known Safety Concerns? (Criminal Record, History of Violence, Weapons in the Home, Sex Offender, General Concerns, etc.)

If none, please enter N/A.
This Section is for the Intake Team ONLY
Is Referral Able to be Enrolled with MHA BCM Services?

Is Referral Able to be Enrolled with MHA BCM Services? Yes No
Who Will be Completing the Intake?
Date of Scheduled Intake Date of Scheduled Intake / MM / DD YYYY
Time of Scheduled Intake Time of Scheduled Intake : HH MM AM/PM

Care Coordination Referral Form

Care Coordination Referral Form

Health Home Eligibility

This Section is for the Intake Team ONLY