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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.
I am
a Patient
a Caregiver
a Case Worker
a Healthcare Provider
Personal Information
Please provide the member's first name
*
First Name
Please provide the member's last name
*
Last Name
Please provide the member's date of birth
*
-
Month
-
Day
Year
Date of Birth
Please provide the member's address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Member's Phone Number
*
Please enter a valid phone number.
Can we text you?
*
Yes
No
Preferred Language or Communication
i.e., English, Spanish, Russian, Hmong, ESL, etc.
Name of Referring Provider and Organization
*
Please provide name of your organization, agency or clinical office - i.e., ABC Hospital, Anytime Agency, County ECM Program, etc.
Referring Provider/Case Manager Contact Information - Email/Phone (if applicable)
Please enter referring person's name and a valid phone number (xxx-xxx-xxxx) or email (example@example.com).
Insurance Information
What health plan is the member associated with?
*
Please Select
Alliance (CCAH)
Anthem
CalOptima
CalViva/Health net
CenCal
Central California Alliance for Health (CCAH)
Contra Costa Health Plan
Inland Empire Health Plan (IEHP)
Kaiser Permanente
Kern Health Systems
Molina
Partnership Health Plan (PHP)
Member ID #
Health Plan ID# or Medi-Cal #
MSSP # (if applicable)
MSSP #
Caregiver's Name (if applicable)
First Name
Last Name
Caregiver's Phone Number (if applicable)
Please enter a valid phone number.
Primary Care Physician
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 Fax Number
Primary Care Physician Email Address
How did you hear about this benefit?
i.e., Dr office, Flyer, Event, Poster, etc.
Medical History
Does the member have one or more of the following medical conditions?
*
Alzheimer's Disease/Dementia
At Risk for Homelessness
Diabetes
Cancer
Chronic Kidney Disease
Chronic Lung Disorder
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure
Extensive Care Coordination Needs
Fatty Liver Disease
Gastrointestinal (GI) Disorders
Gestational Diabetes
Heart Disease
Hepatitis C
High Blood Pressure
High Cholesterol
High-Risk Pregnancy
History of Substance Abuse
HIV
Mental Health Disorder / Behavioral Health Disorder
Obesity
Recent Major Surgery/Trauma
Stroke or History of Stroke
Other
Height
Weight
Do you have any diagnosed food allergies?
*
YES
NO
Please list any diagnosed food allergies:
Please list any food allergies, i.e.,nut allergy, peanuts, fish, dairy, soy, etc.
Have you recently been hospitalized or discharged from a skilled nursing facility?
*
YES
NO
Is the member able to consume solid foods?
*
YES
NO
I consent to receiving services and communications via text and phone from ModifyHealth.
*
Documentation Attachments
Healthcare Providers are strongly encouraged to provide medical documentation on disease state to expedite approvals
Browse Files
Drag and drop files here
Choose a file
Cancel
of
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
Additional Notes (if applicable)
Provide any additional information here
Optional For Healthcare Providers: To receive a copy of this referral, please enter your email below.
example@example.com
Submit
Submit
Should be Empty: