ࡱ> #` Rbjbj hX $P"4V<h<ZZZZ !|"@<<<<<<<$(>h@)<Q# ##)<ZZhz<&&&#^ZZ<&#<&&7|C8Z pAQ$^7O9<0<7A$A$C8AC8 X"L"6&",#X"X"X")<)<&^X"X"X"<####dNN Case Management Referral Form To request Case Management services, please complete the information below and Fax this form to (206) 613-8873 Patient InformationLast Name: FORMTEXT      First Name: FORMTEXT      ID No: FORMTEXT      Date of Birth: FORMTEXT      Phone No: FORMTEXT       Health Care Team InformationReferral Date: FORMTEXT      Referred by: FORMTEXT      Phone No: FORMTEXT      PCP: FORMTEXT      Phone No(s): FORMTEXT      Fax No(s): FORMTEXT       Reason for referral: FORMTEXT      Diagnosis: FORMTEXT      History of present condition:  FORMTEXT      Current services (if known): FORMTEXT      Has the patient or primary caregiver been informed that a CM referral was being submitted? FORMCHECKBOX  Yes FORMCHECKBOX  NoComments: FORMTEXT       Submitting a Case Management Referral: Please fax this referral form, and any additional clinical information that may assist the Case Manager in providing services to your patient, to Community Health Plan at (206) 613-8873. Case Management General Information: CHP provides RN and MSW Case Management (CM) services for patients who: Have a complex medical or behavioral health condition Have high risk psychosocial risk factors For whom CM services would likely reduce patient risk of adverse outcome. :<  B D \ ^ r t v  $ & : ¸ugjhv.0hv.0UjFhv.0hv.0U jhv.0hv.0UmHnHujhv.0hv.0U hv.0hv.0jhv.0hv.0Uhv.0huhv.05:huhv.05:B*phhe'h8CJ aJ hsUhsU>* hsU>*hsUh~L/h f5:h~L/hsU5:$<  D F \ x$Ifgd8Qkd$$Ifs'8(  t 44 sap yt]| $$Ifa$gd8gd8$a$gdsU `RR {{{ x$Ifgd8xkd+$$IfsF&'f  t    44 sapyt]|   {{{ x$Ifgd8xkd$$IfsF&'f  t    44 sapyt]|  $ L N {{{ x$Ifgd8xkd=$$IfsF&'f  t    44 sapyt]|: < > H J L d f z | ~     : < P R T μʱʦʘʐwʘleWlj hv.0hxU hv.0hxjhv.0hxUjhxUmHnHuj hs2UjhxUhxhuhv.05:he'h8CJ aJ hlVhv.0CJaJjhv.0hv.0Uhv.0 hv.0hv.0 jhv.0hv.0UmHnHujhv.0hv.0UjJhv.0hv.0U"N P d {{{ x$Ifgd8xkd$$IfsF&'f  t    44 sapyt]| {{{ x$Ifgd8xkdC$$IfsF&'f  t    44 sapyt]| u $$Ifa$gd6F~gd8xkdP$$IfsF&'f  t    44 sapyt]|   x$Ifgd6F~Qkdk $$Ifs'?(  t 44 sap ytx : b d {{p x$Ifgd6F~ x$Ifgds2xkd $$IfsF&'f  t    44 sapytxT ^ ` b z |      8 : N P R \ ^ ` d h j l ݽݯݡًٖ|u hv.0hjIjhv.0hjIUhjIhe'h fCJ aJ hlVhxCJaJjhv.0hxUj8hv.0hxUjhv.0hxUj2 hv.0hxUhx hv.0hxjhv.0hxU jhv.0hxUmHnHu*d f z {{{ x$Ifgd6F~xkd% $$IfsF&'f  t    44 sapytx {{{ x$Ifgd6F~xkd $$IfsF&'f  t    44 sapytx  {{{ x$Ifgd6F~xkd+$$IfsF&'f  t    44 sapytx " 8 ` b {{{ x$Ifgd6F~xkd$$IfsF&'f  t    44 sapytxb d f h {{ x$Ifgd6F~xkd1$$IfsF&'f  t    44 sapytxh j l zz $Ifgd f & F hh$If^hgd fgd/#`kd>$$Ifs0&'E' t44 sapytx  B D X Z \ f h j n ϼǮǧיӕtphp]jhk74UjhUhjhWUmHnHujSh[UjhWUhWjhv.0hjIU hv.0hy,jhy,UmHnHujh!Ujhy,Uhy,hjI hv.0hjIjhe'Ujhv.0hjIUjhv.0hjIU$  vv $Ifgd f & F hh$If^hgd fjkd$$IfsFe &' m t    44 sayt ?  B j l tt x$Ifgd & F hh$If^hgdjkd $$IfshF&'R  t    44 sayt ?l n ww x$Ifgd h$If^hgdjkdk$$Ifs_FU &' } t    44 sayty, ncc x$Ifgd & F hh$If^hgdzkd$$IfsF &'S  t    44 sapytW "&(*,z|iwzJLtMPP^R`Rټ䟍}vljlf_ hEmhEmhvbUhEmhEm5: hEm5>* hEm5hEm hEm5:#hEmhEm5:B*CJaJph#hEmh85:B*CJaJphhjIhjICJaJjhe'Ujhv.0hjIU hv.0hjIjhv.0hjIUhjIjHhUhjhU#  x$Ifgdjkd$$IfsF"'") t    44 saytW "$&(*31Wkd$$IfsP0$'" t44 sayte' x$Ifgdjkd$$IfsF$&'! t    44 saytW*,z|yz ILLtMvMbNO2PXQQR`RdRfR & F ^gdEm & FgdEm$a$gdEmUpon referral, a Case Manager will screen for the appropriateness of CM services and triage for urgency of initiating CM services. If the CM referral is not accepted, the referral source will be notified and provided with the reason for not accepting the referral. If the referral is accepted, a care plan will be completed and sent to the member s Primary Care Provider (PCP). 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