ࡱ> %` \bjbj h`̟̟ $*%%%PF&<& HhZ'))))z*b+,dGGGGGGG$IhfLGQ.v*v*..G))hPHE2E2E2.))GE2.GE2E2yB|C)N' 6ҙ%]/BDfH0HCL0L$CLC<-LP-6E2-,----GG1X---H....  $& Case Management Referral Form To request Case Management services, please complete the information below and Fax this form to (206) 613-8873  FORMCHECKBOX  Urgent  FORMCHECKBOX  Routine Referral Date:  FORMTEXT       Patient InformationLast Name: FORMTEXT      First Name: FORMTEXT      ID No: FORMTEXT      Date of Birth: FORMTEXT      Phone No: FORMTEXT      LOB: FORMCHECKBOX  BHP  FORMCHECKBOX  HO  FORMCHECKBOX  SCHIP  FORMCHECKBOX  MA  FORMCHECKBOX  GAUCity: FORMTEXT      Member s Preferred Language: FORMTEXT       Health Care Team InformationReferred by: FORMTEXT      Phone No: FORMTEXT      PCP: FORMTEXT      Phone No(s): FORMTEXT      Fax No(s): FORMTEXT       Reason for referral: FORMTEXT      Diagnosis: FORMTEXT      History of present condition:  FORMTEXT      Current services (if known): FORMTEXT      Has the patient or primary caregiver been informed that a CM referral was being submitted? FORMCHECKBOX  Yes FORMCHECKBOX  NoComments: FORMTEXT       Submitting a Case Management Referral: Please fax this referral form, and any additional clinical information that may assist the Case Manager in providing services to your patient, to Community Health Plan at (206) 613-8873. For internal referrals, please route to the Case Management Assistant. Case Management General Information: CHP provides RN and MSW Case Management (CM) services for patients who: Have a complex medical or behavioral health condition Have high risk psychosocial risk factors For whom CM services would likely reduce patient risk of adverse outcome. :<   : < > N P l n p ׹׵~yqfXNhuhv.05:huhv.05:B*phhe'h8CJ aJ h< hy>* h< >*#jh< h< >*UmHnHujh< hM:>*Uh< h< >*jh< h< >*Uh< jvh Ujh UjhyUhyhsUhsU>* hsU>*hsUh~L/h f5:h~L/hsU5:<  N  6 8 zooo x$Ifgd8Qkdb$$Ifs'?(  t 44 sap ytR $$Ifa$gd8gd8 `'gd<  gdygdy$a$gdsU `\\   $ & ( 2 4 6 R T h j l v x z   , . 0 : < > B L N j l n x z |j hyUjhyUhyj/hv.0hv.0Ujhv.0hv.0Uj)hv.0hv.0Ujhv.0hv.0U jhv.0hv.0UmHnHujhv.0hv.0U hv.0hv.0jhv.0hv.0Uhv.008 : R z | {{{ x$Ifgd8xkd$$IfsF&'f  t    44 sapytR| ~ {{{ x$Ifgd8xkd$$IfsF&'f  t    44 sapytR {{{ x$Ifgd8xkd$$IfsF&'f  t    44 sapytR   > @ {{{ x$Ifgd8xkd"$$IfsF&'f  t    44 sapytR@ B L ( * {f{ z Zx$Ifgd x$Ifgd8xkd$$IfsF&'f  t    44 sapytRz    & ( 8 : N P R \ ^ ` d Ǽǵwlhhv.0hlVhv.0CJaJjhRUmHnHujh&UjhRUhRjhyUmHnHuj h U hv.0hyj hM:Uh^:Gjh^:GUj h Uj h UjhyUj( h Uhy'* , 8 ` b {{{ x$Ifgd8xkd $$IfsF&'f  t    44 sapytRb d {{{ x$Ifgd8xkd $$IfsF&'f  t    44 sapytR {{{ x$Ifgd8xkd$$IfsF &' * t    44 sapytR  u $$Ifa$gd6F~gd8xkd$$IfsF&'f  t    44 sapytR   * , @ B D N P R j l   (*>@BLNPTزѤزіزшزzزjhv.0hxUjNhv.0hxUjhv.0hxUjHhv.0hxU jhv.0hxUmHnHujhv.0hxU hv.0hxjhv.0hxUhxhv.0huhv.05:he'h8CJ aJ ,  * R T x$Ifgd6F~ x$Ifgds2Qkd$$Ifs'?(  t 44 sap ytxT V j {{{ x$Ifgd6F~xkd;$$IfsF&'f  t    44 sapytx {{{ x$Ifgd6F~xkd$$IfsF&'f  t    44 sapytx {{{ x$Ifgd6F~xkdA$$IfsF&'f  t    44 sapytx(PR{{{ x$Ifgd6F~xkd$$IfsF&'f  t    44 sapytxRTVX{{ x$Ifgd6F~xkdG$$IfsF&'f  t    44 sapytxTXZ\24HJLVXZ^׺ⶮЀ׺|t|itjih[UjhWUhWj hv.0hjIU hv.0hy,jhy,UmHnHujh!Ujhy,Uhy,jhe'Uj3hv.0hjIU hv.0hjIjhv.0hjIUhjIhe'h fCJ aJ hxhlVhxCJaJ#XZ\zz $Ifgd f & F hh$If^hgd fgd/#`kdT$$Ifs0&'E' t44 sapytxvv $Ifgd f & F hh$If^hgd fjkd$$Ifs?Fe &' m t    44 sayty2Z\tt x$Ifgd & F hh$If^hgdjkd#$$IfsF&'R  t    44 sayty\^ww x$Ifgd h$If^hgdjkd$$IfsFU &' } t    44 saytyz|  jlao{ib^Y^R hEm5>* hEm5hEm hEm5:#hEmhEm5:B*CJaJph#hEmh85:B*CJaJphhjIhjICJaJjhe'Uj!hv.0hjIU hv.0hjIjhv.0hjIUhjIj^ hUjhk74UjhUhhWjhWUjhWUmHnHu zncc x$Ifgd & F hh$If^hgdzkd$$IfsF &'S  t    44 sapytW x$Ifgdjkd $$IfsF"'") t    44 sayty31Wkd #$$IfsP0$'" t44 sayte' x$Ifgdjkd$"$$IfsF$&'! t    44 saytWjlqr*`VVtWvWbXY2ZX[[\ & F ^gdEm & FgdEm$a$gd< $a$gdEmoqTVtWZZ^\`\b\d\f\h\j\l\n\p\r\t\v\x\|\~\\\\j#h< UhIsYhexjhexU hEmhEmhvbUhEmhEm5:h< hEmUpon 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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