CareKit
.net
Dark
menu
CareKit Forms
LA County ECM Benefit Referral Form
Health Plan Selection
Selected Health Plan
*
Anthem Blue Cross
Blue Shield Promise Health Plan
Health Net
Kaiser Permanente
L.A. Care Health Plan
Molina Healthcare of California
Date of Referral
Type Of Referral Routine
Type Of Referral Expedited
Member's Managed Care Plan
Member First Name
Member Last Name
Member Medi-Cal Client Index Number (CIN)
Managed Care Plan Member ID Number
Member Date of Birth
Member Primary Phone Number
Member Preferred Language
Member Primary Care Provider Name
Member Residential Address
No Fixed Address
Member Residential City
Member Residential Zip Code
Member Email
Member Information
Best Contact Phone
Best Contact Email
Best Contact Time
Parent/Guardian/Caregiver Name
Parent/Guardian/Caregiver Phone Number
Parent/Guardian/Caregiver Email
Referring Organization Name
Referring Organization NPI
Referring Individual Name
Referring Individual Title
Referring Individual Phone Number
Referring Individual Email Address
Referring Relationship Medical
Referring Relationship Social
Referring Relationship Other
Provider Type
Community Partner (Non-ECM Provider)
ECM Provider
ECM Provider with Presumptive Authorization
Has Preferred E C M
Yes, Member has a preferred ECM Provider
No, Member does not have a preferred ECM Provider
Preferred ECM Care Manager
Referral Source
Preferred ECM Provider Organization
Should Be E C M Provider
Yes, our organization should be the Member's ECM Provider
No, recommend assigned to different ECM Provider (add detail in Section 5)
No, member wants an alternative preferred ECM Provider
Preferred ECM Care Manager
Preferred ECM Provider Organization
Has Started E C M Services
Yes, Member has already started ECM services
No, Member has not started ECM services
ECM Benefit Start Date
Pof1 Homelessness
Pof1 Experiencing Homelessness
Pof1 Complex Health
Pof2 Avoidable Hospital
Pof2 Five E R Visits
Pof2 Three Hospital Stays
Pof2 At Risk
Pof3 Mental Health S U D
Pof3 S M H S
Pof3 D M C O D S
Pof3 D M C
Pof3 Social Factor
ECM Eligibility
Pof3 High Risk
Pof3 Crisis Services
Pof3 Two E R Visits
Pof3 Pregnant
Pof4 Justice Involved
Pof4 Transitioning
Pof4 Mental Illness
Pof4 S U D
Pof4 Chronic Condition
Pof4 I D D
Pof4 Traumatic Brain
Pof4 H I V
Pof4 Pregnant Postpartum
Pof5 L T C
Pof5 Living Community
Pof5 Lower Acuity
Pof5 Complex Social
Pof5 Able Reside
Other Programs
Pof6 Nursing Residents
Pof6 Interested Moving
Pof6 Likely Candidate
Pof6 Able Reside Community
Pof7 Birth Equity
Pof7 Pregnant Postpartum
Pof7 Racial Disparities
Program D S N P
Program Hospice
Program F I D E S N P
Program P A C E
Program M S S P
Program Self Determination
Program A L W
Program C C T
Program H C B A
Program H I V
Additional Comments
Additional Comments
Exclusion1 Non Active Medi Cal
Exclusion2 Fee For Service
Exclusion3 Hospice
Exclusion4 D S N P
Exclusion5 F I D E S N P
Exclusion6 P A C E
Exclusion7 I C F
Exclusion8 M S S P
Exclusion8 A L W
Exclusion8 H C B A
Exclusion8 H I V Waiver
Exclusion8 D D Waiver
Exclusion8 Self Determination
Exclusion9 Basic Case
Exclusion9 Complex Case
Exclusion10 C C T
Wrap11 C C S
Wrap11 T C M
Exclusionary Screening
Wrap11 S M H S T C M
Wrap11 I C C
Wrap11 D M C O D S
Wrap11 Regional Center
Wrap12 C C S W C M
Wrap12 C B A S
Wrap12 I H S S
Wrap12 Cal A I M
Wrap13 Multiple D S N P
Wrap13 D S N P Look Alike
Wrap13 Medicare Advantage
Wrap13 Medicare F F S
Wrap14 A I D S
Wrap14 F S P
CareKit.netCareKit.net