SmartHealth Care Management Request Form

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Complete this form to refer SmartHealth members to Central Care Management.

Person Completing this FORM (First & Last) *

Member Name: *

Member Date of Birth *

YYYY

Caregiver POC (if applicable):

Member Insurance/Plan Name:
*

SmartHealth

Required

Market (State):
*

Alabama

Florida

Illinois

Kansas

Maryland

Indiana

Oklahoma

Michigan

New York

Tennessee

Texas

Wisconsin

Non-Ascension Market

Referral Source:
*

Patient/Self Referral

PCP/Provider referral

Care Manager/Care Team patient referral

Patient Coordination Team

Utilization Management

Benefit Bump

Specialty Pharmacy Team (ARx)

Required

Please select the reason for referral (Select all that apply):

Disease/condition (disease management or complex care management)

Assistance with medications

Education

Recent medical admission or emergency room visit

Recent behavioral health admission or emergency room visit

Behavioral health conditions

Wellness (weight management, tobacco cessation, stress management)

Resources

Maternity benefits

High risk pregnancy

Other:

Required

Further details or additional comments for referral:

(Please provide details on reason for referral)

Member's call-back number as well as the most convenient time for a Care Manager to reach out:
*

Communication Barriers (Hard of hearing, etc.):

Submit

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