Intensive care management (ICM) referral

Patient/member name

Date of birth

Address

City

State

ZIP Code

Phone number or best way to contact

Best time(s) or day(s) to contact

Primary language

Does member need an interpreter?

Yes

Primary diagnosis

Contact person for this referral

Phone number

Referral made by

Have you discussed this referral with this patient?

Yes

Referrals are not accepted until you have discussed it with the member.

Provider Contact Information

Provider name

Provider phone number

Provider fax number

Check all the appropriate boxes to explain the reasons for this referral:

Need/trigger	Please give details of the need/trigger (type of referral)
Complex medical needs/multiple chronic conditions
Behavioral health needs
3 ED visits or unplanned hospital admissions in last 6 months
Care coordination, primary care needs

Please provide a brief explanation of the goal/desired outcome with ICM identified during discussion with the patient/member:

Check if you would like a copy of this form sent to you via email

Email address

Please re-enter your email address to confirm

By clicking 'Submit', this referral will be sent via secured email.

However, if you would prefer to print the PDF and fax manually, you can click 'View/Print PDF', print and fax to (612) 336-1370. All required fields must be entered prior to Viewing/Printing. The PDF may automatically download depending on your browser's settings.