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Referral Intake Form
Kindly complete this form to the best of your ability. Please note that certain insurance plans may require additional medical documentation. If you are a licensed medical professional, we request that you attach the relevant medical documentation to support the member's request.
Personal Information
Member's First Name
*
First Name
Member's Last Name
*
Last Name
Member's Date of Birth
*
-
Month
-
Day
Year
Date of Birth
Member's Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Member's Phone Number
*
Please enter a valid phone number.
Can we text member?
*
Yes
No
Preferred Language
i.e., English, Spanish, Russian, Hmong, ESL, etc.
Insurance Information
Member's HealthPlan
*
Please Select
Anthem Blue Cross California
Central California Alliance for Health (CCAH)
Contra Costa Health Plan (CCHP)
Health Net of California and Oregon
Inland Empire Health Plan (IEHP)
Kern Health Systems
Molina Healthcare of CA
Other
HealthPlan
Other HealthPlan
Please Select
Cal-Viva
CalOptima
Kaiser Permanente
LA Care
Humana
Partnership Health Plan (PHP)
WellCare
Member ID #
Health Plan ID# or Medi-Cal #
MSSP # (if applicable)
MSSP #
How did you hear about this benefit?
i.e., Dr office, Flyer, Event, Poster, etc.
Member's Height
Member's Weight
Medical History
Does the member have one or more of the following medical conditions?
*
Alzheimer's Disease/Dementia
At Risk for Homelessness
Diabetes, Type 1
Diabetes, Type 2
Cancer
Chronic Kidney Disease / Renal Disease
Chronic Lung Disorder
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure (CHF)
Enrolled in ECM (Extensive Care Coordination Needs)
Fatty Liver Disease / NAFLD
Gastrointestinal (GI) Disorders
Gestational Diabetes
Heart Disease / Cardiovascular Disease
Hepatitis C
High Blood Pressure / Hypertension (on meds)
High Cholesterol
High-Risk Pregnancy
Post Partum
History of Substance Abuse
HIV / AIDS
Severe Mental Health Disorder / Behavioral Health Disorder
Obesity
Recent Major Surgery/Trauma
Stroke or History of Stroke
Other
Other Medical Conditions
Have you recently been hospitalized or discharged from a skilled nursing facility?
*
YES
NO
Is the member able to consume solid foods?
*
YES
NO
Please list any clinically documented food allergies:
*
No Known Food Allergies
Bell Pepper - BP
Beans - BE
Soy - SY
Dairy - DI
Tree Nuts - TN
Chicken - CH
Curry - CY
Lamb - LB
Pork - PK
Eggs - EG
Gluten - GL
Sesame - SE
Fish - FS
Shellfish - SS
Spicy - SP
Mushroom - MR
Rice - RC
Red Meat - RM
Turkey - TK
Beyond Meat - BM
Daring Chicken - VC
Wheat - WH
Chia - CI
Cilantro - CL
Olives (pieces) - OL
Eggplant - EP
Garbanzo Beans - GZ
Squash - SQ
Secondary Contact
Caregiver's Name
First Name
Last Name
Caregiver's Phone Number
Please enter a valid phone number.
Primary Care Physician
PCP Phone Number
PCP Phone Number
PCP Fax Number
PCP Fax Number
*ECM Provider Organization
Ex: ABC Hospital, Anytime Agency, etc.
*ECM County Serving
Provider County
*ECM Referring Case Manager
CM's First Name
CM's Last Name
*ECM Case Manager's Phone
Please enter a valid phone number.
*ECM Case Manager's Email
example@example.com
I consent to receiving services and communications via text and phone from ModifyHealth.
*
Documentation & Attachments
Attach medical documentation on disease state to expedite approvals
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Optional: Enter email to received official copy of this MTM.
Healthcare Provider's Email
Additional Notes
Provide any additional information here
Submit
Submit
Please list any diagnosed food allergies:
Please list any food allergies, i.e.,nut allergy, peanuts, fish, dairy, soy, etc.
Primary Care Physician Contact Information - Phone/Fax/Email
Please enter valid phone number (xxx-xxx-xxxx), fax xxx-xxx-xxxx email (example@example.com).
Primary Care Physician Email Address
Caseworkers are highly recommended to provide medical documentation on disease state to expedite approvals
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please provide medical documentation on disease state to expedite approvals
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Should be Empty: