Get the free Care Management Referral Form - Anthem

State Sponsored Business Care Management Referral Form This section to be completed by the person submitting the referral to Care Management or Continuity of Care. Member Name: DOB: Member Phone Number:

How to fill out care management referral form

How to fill out a care management referral form:

1. Start by providing your personal information, such as your name, address, phone number, and date of birth. This is important for identifying the person requiring care management services.
2. Next, include the contact information of the person making the referral or the care provider who will be responsible for managing the individual's care. This may include their name, address, phone number, and email.
3. Specify the reason for the care management referral. This could be due to a chronic illness, disability, aging-related issues, mental health concerns, or any other condition requiring specialized care.
4. Include relevant medical information about the individual, such as their current diagnoses, medications, allergies, and any recent medical procedures or hospitalizations. This information helps the care manager understand the individual's health status and create an appropriate care plan.
5. Provide details about the individual's current living situation, including whether they live alone, with family, or in a care facility. This information can help determine the level of support required and any necessary arrangements.
6. Describe the challenges or issues the individual is facing that require care management assistance. This could involve difficulties with medication management, coordinating medical appointments, accessing community resources, or any other challenges related to their health and well-being.
7. If available, attach any relevant medical reports, care plans, or relevant documentation that can provide more insight into the individual's condition and care needs.

Who needs a care management referral form?

1. Individuals with chronic illnesses who require ongoing coordination of care from multiple healthcare providers.
2. Older adults with complex medical conditions that necessitate regular monitoring and assistance in managing their health.
3. Individuals with disabilities or special needs who require support services and care coordination.
4. Patients with mental health conditions who require assistance in accessing mental health resources, therapy, and medication management.
5. Individuals being discharged from a hospital or rehabilitation facility who need guidance and support in transitioning back to their home or community.
6. Family members or caregivers who are struggling to manage the care and support needs of a loved one and require professional assistance and guidance.
7. Anyone who recognizes the need for coordinated care and support in managing their health and well-being but may not know where to start or how to access appropriate resources.

For pdfFiller’s FAQs

What is care management referral form?

The care management referral form is a document that is used to refer individuals to a care management program or service.

Who is required to file care management referral form?

Healthcare professionals or providers who assess a patient's need for care management services are required to file the care management referral form.

How to fill out care management referral form?

To fill out the care management referral form, the healthcare professional must provide the patient's personal information, medical history, current health conditions, and reason for the referral.

What is the purpose of care management referral form?

The purpose of the care management referral form is to facilitate the coordination of care for patients who require additional support and assistance in managing their healthcare needs.

What information must be reported on care management referral form?

The care management referral form typically requires information such as the patient's name, contact details, medical history, current health conditions, and the referring healthcare professional's information.

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