Complex Case Management Referral Form

Email address *
Complex Case Management is an enhanced service that assists people in coordinating all of their immediate healthcare and community resource needs. The service is only available for individuals currently receiving services through OCHN's network, who have active medicaid, and who meet two or more of the criteria provided in this form.
Please check the service criteria listed below that applies to the individual being referred. (If two or more criteria are not selected, it is not necessary to complete and submit the form.) *
Required
First and last name of individual being referred *
Your answer
Individual's mailing address *
Your answer
Individual's contact phone number *
Your answer
Case manager's name and contact information *
Your answer
Medicaid number
Your answer
Birthdate *
MM
/
DD
/
YYYY
Individual's primary language
Your answer
Diagnoses
Your answer
Last known primary health care provider visit
MM
/
DD
/
YYYY
Prescribing mental health practitioner (MD, PA, NP, etc.) *
Your answer
Core provider agency *
Medicaid health plan
Give a brief description of why the individual is being referred. *
Your answer
Does the individual have a guardian? *
Was the individual or authorized representative informed of this referral? *
Submit
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