Care Management Referral Form

Care Management Open Referral Form

Identify TRICARE beneficiary

Beneficiary first name* Beneficiary middle name Beneficiary last name* Beneficiary suffix name TRICARE ID*

Beneficiary date of birth* Beneficiary email address Beneficiary home phone* Beneficiary work phone Extension

*Please ensure all required fields are filled in

Beneficiary first name is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Beneficiary middle name is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Beneficiary last name is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Beneficiary suffix name is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

TRICARE ID is not valid: it must contain between 9 and 11 numbers

Beneficiary date of birth is not valid: it must be a date

Beneficiary email address is not valid: it is not properly formatted

Beneficiary home phone is not valid: it must contain exactly 10 numbers

Beneficiary work phone is not valid: it must contain exactly 10 numbers

Beneficiary work extension is not valid: it must contain only numbers

Referral information

Point of Contact (POC)* Referral date* POC phone number*

POC extension POC fax number POC email address

Physician

Physician first name* Physician last name* Physician suffix Physician title Physician phone* Physician extension

Specialty* Mailing address* Mailing address line 2 City*

ZIP Code*

*Please ensure all required fields are filled in

Point of Contact (POC) is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Referral date is not valid: it is not a valid date

POC phone number is not valid: it must contain exactly 10 numbers

POC Extension is not valid: it must contain only numbers

POC fax number is not valid: it must contain exactly 10 numbers

POC email address is not valid: it is not properly formatted

Physician first name is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Physician last name is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Physician suffix name is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Physician title is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Physician phone number is not valid: it must contain exactly 10 numbers

Physician extension is not valid: it must contain only numbers

Specialty is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Mailing address is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

Mailing address line 2 is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

City is not valid: it must contain only alphanumeric characters, spaces, apostrophes, underscores, periods, and dashes

State is not valid: please select a state

ZIP code is not valid: it must contain exactly 5 numbers

Referral reason

Select most appropriate referral reason*

Anxiety Education/Disease management

Asthma Education/Disease Management

Beneficiaries with insufficient supports causing significant impairment or stress

Beneficiaries with support or resource needs who are unable to navigate system

Beneficiary failure to follow through with PCM recommendation for mental health treatment

Beneficiary transfer requiring coordination

Burn injury requiring a burn unit

CAD (Coronary Artery Disease) Education/Disease Management

Catastrophic illenss or injury, amputation, multiple trauma

CHF (Congestive Heart Failure) Education/Disease Management

Chronic condition resulting in high resource consumption (e.g. hemophilia, Gaucher's disease)

Chronic suicidal, lethal, dangerous behaviors

Congressional or high profile case

COPD (Chronic Obstructive Pulmonary Disease) Education/Disease Management

Diabetes Education/Disease Management

Dual Behavioral Health diagnosis clients with 2 or more relapses or hospitalizations in one year

Eating disorder patient has exhausted her yearly benefit

ECHO other than behavioral health diagnoses

High utilization of services, including multiple providers without coordination of care

History of discharge against medical advice with no discharge plan

Hourly Nursing more than 4 hrs/day

Humana at Home for MTF Discharge

Hypertension Education/Disease Management

Major Depressive Disorder (Depression) Education/Disease Management

Medical and mental health co morbidity needing facilitation of communication between providers

New quadriplegic or paraplegic

Newly diagnosed patients requiring assistance with education about their illness and resources

Planned Long Term Acute Care (LTAC) admission

Post Traumatic Stress Disorder in ADSM

Post Traumatic Stress Disorder in non ADSM

Pregnancy with significant identified risks

Premature Infant, ventilator dependent >24 hours and/or weight less than 1500 grams

Referral to Residential Treatment Centers (RTC) has been denied

Repeated non-compliance with recommended treatment resulting in higher levels of care

Transfers requiring case manager assistance with coordination

Transplantation Evaluation or procedure (Solid organ or bone marrow/peripheral stem cell)

Traumatic Brain Injury, Spinal Cord Injuries, stroke, blindness

Unplanned admissions to acute hospital 3 times or more within 90 days with same diagnosis

Unstable beneficiary with multiple providers and high dollar utilization requirements

Ventilator dependent beneficiary

Please describe: diagnosis, clinical history, reason(s) for referral*

*Please ensure all required fields are filled in

We are sorry, there was a problem submitting your referral. Please check for errors in the form and resubmit. If that doesn't solve the problem, please try again later.

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