CalAIM / ModifyHealth MTM Referral Form

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.
- Lead Source
- Member's First Name
  First Name
- Member's Last Name
  Last Name
- Member's Date of Birth
  
  MonthDayYear
  Date of Birth
- Member's Address (No P.O. Box please)
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Cellphone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Home Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Member's Email
  example@example.com
- Can we text member?
- Spoken Language
- Member's HealthPlan
  HealthPlan
- Other HealthPlan
- Member ID #
  Health Plan ID# or Medi-Cal #
- Missing Member ID?
- MSSP # (if applicable)
  MSSP #
- How did you hear about this benefit?
- Member's Height
- Member's Weight
- Does the member have one or more of the following medical conditions?
- Other Medical Conditions
- Please list your current medications, if any:
- Have you recently been hospitalized or discharged from a skilled nursing facility?
- Discharge Date
  
  MonthDayYear
  Date
- Are you currently enrolled in ECM?
- Are you able to consume solid foods?
- Note: meals are only available in solid foods with regular texture, and at this time we do not offer any modifications (e.g. chopped, pureed).
- Please list any clinically documented food allergies:
- Do you have a safe place to store and heat meals?
- Anything else you would like us to know about your medical history?
  Provide any additional information here
- Attach medical documentation on disease state to expedite approvals
  
  Cancelof
- Last A1C Results
  Ex. 7.5%
- Last A1C Result Date
  
  MonthDayYear
  Date
- EF Percentage (%)
  Note: A healthy heart typically has an EF between 55-70%
- Last Blood Pressure Reading
  Ex. 120/80
- Last Blood Pressure Reading Date
  
  MonthDayYear
  Date
- Chronic Kidney Disease
- Serum Albumin Level
  Note: A normal level is between 3.4g/dL to 5.4 g/dL
- If has COPD: Is the member currently on oral steroids?
- Are you up-to-date on your PCP visit?
  
  Yes, Enter Date
- Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?
- Weight loss during the last 3 months?
- Mobility
- Has suffered psychological stress or acute disease in the past 3 months?
- Neuropsychological problems
- Please indicate the member’s Shopping and Food Preparation abilities below:
- Does the member currently have In-Home Supportive Services (IHSS)?
- Is the member currently receiving any of the following supplemental food sources? (Check all that apply)
- Caregiver's Name
  
  First NameLast Name
- Caregiver's Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Primary Care Physician
- PCP Phone Number
  PCP Phone NumberFormat: (000) 000-0000.
- PCP Fax Number
  PCP Fax Number
- Referring Provider Organization
  Ex: ABC Hospital, Anytime Agency, etc.
- County Served
  Provider County
- Referring Provider/Case Manager
  
  First NameLast Name
- Referring Provider/Case Manager's Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Referring Provider/Case Manager's Email
  example@example.com
- Note: If the member is under 18 years of age, then please provide guardian's name and/or relationship to the member.
  Relationship & Name of the guardian
- I consent—or, if under 18 years of age, my legal guardian consents—to receiving services and communications via text and phone from ModifyHealth. I also authorize ModifyHealth to use and disclose my health information, as necessary, to coordinate care, deliver services, and communicate with my healthcare providers, health plan, or other involved parties in compliance with applicable privacy laws, including HIPAA.
- Optional: Enter email to received official copy of this MTM.
  Healthcare Provider's Email
- 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
  
  Cancelof
- Please provide medical documentation on disease state to expedite approvals
  
  Cancelof
- Preferred Language
  i.e., English, Spanish, Russian, Hmong, ESL, etc.
- Should be Empty:

Referral Intake Form