Enhance Care Management Referral

Please Add All Available Information.

Date of Request

Member Information

First Name *

Last Name

Date of birth *

Phone *

Email *

Language

Member's Preferred Language

Member's Medi-Cal Client ID Number

GCHP

Yes

Kaiser

Yes

CenCal Health

Yes

Social Determinants of Health (SDOH) ICD-10 Diagnosis Identified within prior 12 months [Check all that apply]:

Referral Source Information

Referral By

Hospital

SNF

Outpatient Clinic

Community Outreach

Organization

Referrer's Name

Referrer's Phone

Referrer's Fax

Referrer's Email

Referring/Attending Provider

Referral Information

Expected Discharge Date

Diagnoses/Reason(s) for Admisson

Any Known Allergies

Any Dietary Restrictions

Attach a List of Other Known Medical Conditions

TB Test or Chest X-Ray Performed

Yes

Any Communicable Disease (If YES, please attach documentation)

Yes

Attach Communicable Disease Documentation (if applicable)

Colonized (If YES, please attach documentation):

Yes

Colonized Documentation (if applicable)

Covid-19 Test Performed (If YES, please include documentation):

Yes

COVID-19 Test Documentation (if applicable)

Wound Care

Does Member Require Wound Care?

Yes

Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL)

Is Member Independent with IADLs?

Yes

Is Member Independent with ADLs?

Yes

Additional Clinical Information

Does Member require Physical Therapy?

Yes

Does Member require Medication Management and Education

Yes

Does Member require Medication? (If YES, please attach Rx list):

Yes

Attach Medication List

Please Attach the Following Information If Available

Attach Consent Form

Attach Release of Information

Attach Face Sheet

Attach CXR or PPD (TB)

Attach History & Physical

Attach Social Worker Notes

Attach Consultation Notes

Attach Recent PT/OT/Speech

Covid-19 Test result (within last 24 hours)

Wound Care Notes

Psych Notes (please include last 2 days of nursing documentation)

Home Health Provider Info

Attach Any Other Files

Additional Comments